Why the VT shootings can happen again

The shooter was identified as being way more than two bubbles off level, was actually sent for a psych eval; the rest is history.

I have no illusions this couldn’t happen here in Texas.

In California, there are pretty liberal “5150” laws (the section of the Mental Health code that applies to emergency detention of psychiatric patients), and as one Officer eloquently explained “It’s an easy form to fill out”.  Apparently peace officers in California have some immunity for action based on a 5150 complaint, because I saw a lot of them.  My residency training program saw and ‘medically cleared’ at least 20 every night, then they went to an up to 72 hour hold, during which they’d be seen by a psychiatrist or two, and if felt to need more stabilization, a Judge was asked to act to hold them involuntarily for treatment.  I saw more than a couple of patients with 5150 tattoos (one on his knuckles), and they were pretty easy to clear.  Also, geographically defined, if you catch my drift.

That’s the way it worked optimally.  Occasionally we’d get a guy who said “this is what my girlfriend does every time she’s mad at me: she calls the cops, says I’ve taken an OD, and then tells them I’ll deny everything, so they bring me in here on a 5150”; his story would eventually check out, and he’d go home from the ED.  The vast majority were modestly to deeply disturbed patients who really needed the help.  I would have cared more, but I was a resident, and behavioral health evals could suck the life right out of you.  And the less said about the psych residents the better.


Here in Texas, there’s a great emphasis on personal liberty (“It’s not against the law to be crazy”), and that’s good the vast majority of the time.  There is indeed an emergency mental health code for the psychotic, deranged and suicidal, and it’s not easy to utilize.  There is no simple form, but a multipage affidavit that has to be signed by a judge prior to holding a patient for involuntary psychiatric evaluation, and that’s assuming you can get an officer to initiate the form in the first place (mere physicians cannot).  For a police officer to begin the paperwork, the patient must be in imminent danger of harm to self or others due to mental illness.

And, there’s the rub.  As the patient is in an ED, the cops tell us ‘they’re not in imminent danger, as they’re here in the ED’, and they refuse to initiate a hold.  It doesn’t matter to them that we have no psych facilities, that the patient refuses to agree to go voluntarily to a psych facility, they’re just not going to even try.  This puts the ED doc in a tough position (understatement), and there are some work arounds, but it can take hours and hours, and usually doesn’t result in the patient getting the help they need. 


Mental health laws are one of the things I’d like to see addressed in the country well before we try to change anything else.  I’m not going to hold my breath.


  1. This is a common refrain, “mental health laws need to be addressed”, but what do people want that would be constitutional?

    We will not see people put in mental institutions just because their thinking is not right. First of all, this is a judgment call that is harder to make than it seems, plus the fact that the cost is not something that the country wants to bear. There is probably more risk from all the criminals being released because prisons are overcrowded — another example of the lack of will to spend the money.

    It’s easy to look in the retrospectoscope from a tragedy like VT and say, “something should have been done.” The rarity of this event says more than anything about the difficulty if not impossibility of successfully preventing this regardless of how much we spend, in the mean time turning our society into one in which we look for signs of mental illness in everyone we meet, ironically creating a societal paranoia.

  2. Bad Shift says:

    Me: county ER doc in CA.

    Every drunk or minor trouble-maker in town ends up on a 5150. They scoop ’em up and bring ’em in, then cite/release them. I call psych, they release the 5150 hold. Guess who’s stuck with the disposition? You guess it. Around here, the 5150 is just a way to legally round up unsavory folks and dump them on us.

    The same people who are calling the police for drunks in the park are the same ones who are upset that the ER is full of drunks and they have to wait 5 hours to be seen.

    If I have a point, it’s probably that 5150 doesn’t really solve anything. Most of the people they use it for would have been better off sleeping it off in the park.

  3. You make an interesting observation with your statement: “Mental health laws are one of the things I’d like to see addressed in the country well before we try to change anything else.”

    I’m assuming you mean the question about whether or not the country should change to universal health care.

    Because that brings up an interesting question: Besides the whole medical/physical scene universal health plans would deal with, I wonder what universal health would mean to the mental health care in this country?

    As it stands right now in Texas, it’s near impossible to get somebody into MHMR mental health hospitals. You have to be actively suicidal or crazy-type homicidal. All of the MHMR campuses have down-sized to the about 1/4 of the size they were a few years ago.

    So if there were universal health, would the whole system have to be beefed up again? With outpatient clinics to boot? And would that mean that just anybody could walk into an ER and c/o mental health issues and be put into the system?

    It adds a whole new dimension to the universal health issue that I admit that I hadn’t even thought of before.

  4. Jim in Texas says:

    Evil such as this is inevitable, unpredictable and thus unpreventable. Everyone should think what they would do in a similar situation and then plan for it. People like Cho want to, for a brief moment, be “in charge,” be feared. As for how crazy he was, well, I realize that’s a subjective thought but he was clever enough to protect himself from the only people with weapons, the campus police, on the campus by locking the doors.

    “Gun Free Zones” are stupid and I hope Texas follows Tennessee’s lead in reversing that here. What would you rather have in class, 20 complete strangers who have been authorized to carry concealed weapons or one Cho?

  5. TheNewGuy says:

    I don’t disagree that better resources need to be in place for mental health patients… I’m just not sure the VT shooter would have been caught in that dragnet.

    He wasn’t nuts in the traditional sense. I never got any sort of sense that he had an underlying thought disorder. Far from being disorganized, his actions showed forthought; he was goal-directed and logical. He may have been anhedonic, or simply a hate-filled antisocial… but neither of those usually justify incarceration or institutionalization.

  6. When I worked in Minnesota, we had the 72-hour hold that was placed by the ED physician. If the patient needed to be seen by a psychiatrist, they got to spend some time in the locked unit.

    The police could bring them in, but they were held in the security unit until seen by the MD, then if they needed to stay they were placed on the hold. If they didn’t it, they were left with the police to disposition.

    AS for Cho, giving the reason that he was “bullied” in high school and finally took action 4 years later just doesn’t hold water. If it was back in high school why not do the shooting there? No that is just an excuse for the fact that he had a mental problem it was looked in to but there was no follow-up. If one of the teacher had to one-on-one with him because he upset the class, this was not a small problem.

    Whose to blame; his parents, the teacher, the campus mental health system? No!! Cho is to blame, he had an opportunity to get help, it was available, he chose not to take it.

    Will it happen again? Yes. Sometime, somewhere, somehow a crazy person will show up with a gun and start firing.

  7. It’s different in Georgia. They are typically brought through the ER for medical clearance and documentation on a 10-13 form for involuntary commitment. Doc only needs to sign that the patient presents a danger to himself or someone else. Mental health access line is called and does their own eval in the ER and then if accepted by the psychiatrist on call for the local CSU (which they have no choice but to do if the 10-13 is signed), they get wait-listed for a bed. Meanwhile the ER holds them. Sometimes law enforcement is present, sometimes not but once that paper is signed they CAN’T leave. If they do, police are called to pick them up. I’ve seen them get the bloodhounds from the local prison out looking for one who eloped from the ER. It’s getting better, actually, with the hospitals and the law enforcement community raising all sorts of Cain to the State about the wait list so they are usually out of the ER and on their way by sheriff deputy in a matter of 4-6 hours.