By IVEY DeJESUS

pennlive.com

HARRISBURG (TNS) — Amy Graf has spent the better part of the last 12 years watching her son battle debilitating mental illness.

Five years ago, he decided to go off his medications; his condition worsened almost immediately. He went into a catatonic state, unable to eat or sleep, and spent days on end sitting in a chair, staring into space.

Graf contacted crisis intervention but they determined that her son’s condition – schizophrenia and psychosis disorder – did not warrant involuntary commitment because he was not a threat to himself or others.

For more than three years, with the exception of a short stay at an extended care facility in York County, her son, now 38, has languished in a hospital psychiatric unit, waiting to be admitted into a state hospital.

The wait has been arduous, inching in increments from the twelfth spot when he entered hospital, to second or third place — waiting for a bed to become available to get the treatment he needs.

Two weeks ago when Cody Balmer was arrested in connection to the firebombing of the Governor’s Residence, Graf read news accounts that seemed all too familiar to her.

The suspect’s mother, Christie Balmer, had tried to have her son involuntarily committed because he stopped taking his medication for schizophrenia and bipolar disorder and was acting erratic.

But police determined that Cody Balmer did not meet the threshold for involuntary commitment. In the early morning hours of April 13, Balmer, also 38, threw two Molotov Cocktails into the Governor’s Residence in Harrisburg, torching the home while Gov. Josh Shapiro and his family of slept inside, police say.

“For family members, it’s so frustrating that a person has to commit a crime or almost commit a crime – they have to really be up against crossing the line to criminal activity or self-injury before they can be admitted involuntarily,” Graf said. “Neither of which is what a family member wants to see. We don’t want to see our loved one hurt himself or commit a crime. But that’s really the point he has to be at before he can be committed involuntarily. That’s what’s difficult for us as family members.”

For Graf, and other parents and relatives of people battling mental illness, navigating what they say is a chronically underfunded system bound by strict and at times restrictive legal framework, has hampered their ability to get the appropriate and timely treatment their loved ones need.

“For the last nearly four years, he’s been living in a hospital,” Graf said. “He’s been pacing up and down a hallway and building Legos….. There are people who have schizophrenia who do make meaningful recovery and can have a life and get married and have a family with appropriate continued treatment. But, you know, there’s many, probably many more cases who decide, I don’t need treatment anymore. I feel pretty good now. Stop taking my meds. And then the roller coaster starts again.”

Graf’s experience and that of Christie Balmer, who in a lengthy interview with PennLive outlined her failed attempts to secure treatment for her son, underscore the challenges of Pennsylvania’s mental health law governing the involuntary commitment of an individual in order to provide them with treatment, therapy and medication.

The Mental Health Procedures Act of 1976 sets standards by which an individual can be involuntarily committed for mental health treatment – without their consent – giving family members, loved ones and police the ability to initiate a petition. The underlying criteria: that the individual is a danger to self or others. Based on the petition – commonly referred to as a 302 commitment – a physician then determines whether the individual meets the criteria for involuntary commitment.

Many experts consider the preferred option to have the individual willingly involved and invested in getting mental health treatment on a voluntary basis. “That’s clearly where you want folks to really be able to have enough insight that they take their meds or they keep up with their counseling, or they see their doctor or their psychiatrist on a regular basis,” said Joan Erney, a retired deputy secretary of the state Office of Mental Health and Substance Use Services.

In the absence of that individual volition, an involuntary commitment may become necessary, but it hinges on that strict criteria of presenting a danger to self or others.

“It can’t be enough that I say I want to go hurt some anonymous person that is in another country,” Erney said. “That wouldn’t be a sufficient petition. It would be if I said I’m going to go hurt Joan, and I have the means to do that. So I have a gun in the house or I have a knife or and I’m going to do it. So the more specificity, the more likely the petition is held. It’s a multi-step process to ensure that someone’s rights aren’t taken away without major costs. So again the dangerousness.”

Similarly, Erney added, it’s not enough that someone may threaten to commit suicide to warrant a 302.

“It’s really if you’re threatening to hurt yourself, and you actually have pills that you can overdose on, or you have a gun in the house that you have access to, or you, you make a specific plan,” she said. “It’s really do you have those? Do you have the kind of evidence that that person really is going to further the act?”

Additionally, under the law, the criteria has to be valid within the last 30 days to initiate a 302 commitment.

Often, however, an individual in the throes of a mental health episode or phase may seem fine to authorities and medical personnel. That seems to have been the case with Balmer; it was so with Graf.

“Sometimes people will sound pretty coherent,” Erney said. “And so you don’t know that behind that is some paranoid delusion or something really dangerous.”

That’s one of the fault lines in the system, she noted: that mental health professionals and police may not be as attuned to the individual’s condition as that of the family. That can impede the commitment procedure, which requires documentation of evidence and activity establishing danger.

“I do think families feel frustrated when they know their loved one and they know that there’s signs, and they become fearful that those signs are going to end up with something really bad. And that isn’t usually enough to get someone committed,” Erney said. “What you’re usually trying to do in that case is get them into an outpatient appointment or get them in to see a doctor or get them in to see somebody, but as an adult, he would have the right to refuse.”

The law was written to protect individuals from being victims of abusive family members, perhaps seeking revenge for something they have done or said.

Still, Graf believes families should have a bigger stake in the process.

“I feel that it’s the family members or the people who live with that individual who know when they’ve turned that corner, when things are just going downhill and they’re not going to be able to pull themselves back up,” she said. “I wish that the hospitals and crisis intervention could put more stake in what the family members are telling them than what they observe at that moment because it’s truly amazing how a person who is experiencing a psychotic episode can seem pretty normal when a stranger is asking them questions. They can kind of turn it off for the time being and not make that criteria to be admitted.”

In 2019, Pennsylvania amended its mental health law, allowing for an individual to receive assisted outpatient treatment – or AOT — involuntary treatment, such as mandated therapy or day programs while living in the community. Under the broader scope of the law, an individual can qualify for AOT if clear and convincing evidence that the person would benefit from it is established.

Many counties have opted out of an AOT, however, largely due to inadequate, or nonexistent infrastructure. Erney notes that AOT also requires the individual to be engaged with the mental health community and the mental health system to get treatment.

“It is not a very effective tool,” she said.

The more effective tool, Erney argues, is a Psychiatric Advanced Directive, a rarely used option that has been on the books for years. The law allows someone of sound mind to identify someone to act in their stead, permitting them to voluntarily commit them into a hospital or treatment center.

“For people with mental illness, it ebbs and flows,” Erney said. “When they are better and they’re feeling better and they’re healthy, that’s when you have them sign. So that, when they’re not healthy, when they stop taking their meds… you have the directive in place. Somebody can intervene and have them admitted.”

Ultimately, the biggest tool boils down to funding, which over the years, has continued to decrease. Pennsylvania, in fact, has historically ranked among the top tier of states in terms of funding mental health services, largely because programs are county based and funded by Medicaid, but the program does not cover everyone.

In the meantime, the state hospital system has continued to shrink for the last 20 years, with more state hospitals closing annually.

“And private insurance has never paid its fair share to support people with mental illness, even though it’s a health care condition,” Erney said. “And neither has base funding, which is funding that goes to the counties. It has not necessarily kept pace with what it should for folks who don’t reach Medical Assistance.”

Funding losses from the scaling back of the Affordable Care Act is poised to significantly reduce help lower-income people.

Erney argues that the optimal strategy is to fund the mental health system, ensuring that individuals in need are seen by medical professionals, case managers, and that families get the support they need.

“There are a lot of tools in our toolkit that we know how to use and help people with mental health challenges, but it does require funding,” she said.

Graf has become an advocate for reform, calling specifically for more capacity in community- based facilities like group homes, long-term structured residences, and community rehabilitation residences.

As far as her son is concerned, Graf is a proponent of community- based residential facilities, which would allow him, once he’s recovered, to move back into the community, creating capacity at the state hospital level for those who need acute care.

That system of continuum care is a logjam, she said. That hurts her son, and others like Cody Balmer, who need immediate intensive treatment.

“I feel for his family and the frustration that they’ve had trying to get him appropriate treatment,” Graf said. “Ever since my son was put on the wait list for the state hospital, I have this survivor’s guilt, like he’s in a good, safe spot now, even though he’s not getting as intensive treatment as he should be getting to make a better recovery.

At least he’s in a place where he’s being monitored. And that takes some stress off of me. But he’s occupying a bed that should be available for a person with an acute need like Cody Balmer to come in when they’re really in a bad condition. My son is hogging up that bed.”