Proposed law would allow for mandated outpatient treatment

Massachusetts is one of only three states, along with Connecticut and Maryland, that does not allow court-ordered outpatient treatment for people deemed to be a potential danger to themselves or others. A bill currently before the state’s Joint Committee on Mental Health would change that fact.

If passed, H2121 would allow for mandated outpatient treatment, also known as assisted outpatient treatment (AOT), in cases where a person with mental illness is deemed likely to cause harm, or is incapable of making informed decisions, or has a condition that will deteriorate or not improve without treatment.

“Creating an AOT law in Massachusetts would benefit the most severely mentally ill individuals who are now trapped in an endless revolving door leading to hospitalization and incarceration,” said Representative Matthew Muratore (R-Plymouth), one of the bill’s co-sponsors.

“The goal is to break this cycle by maintaining the continuity of care once an individual is released from an inpatient hospital setting or from incarceration.”

The law, according to Muratore, would improve multiple outcomes by providing a layer of mandated care that is one step down from inpatient commitment.

“The goal is to avoid the need for inpatient hospitalization, as well as involvement with law enforcement and the criminal justice system,” said Muratore. “In addition to hospitalization and incarceration, AOT has also been shown to reduce the incidence of homelessness, violent episodes, victimization, and arrests.”

In 2015, the American Psychological Association released a position statement in support of mandated outpatient treatment, saying that it “can be a useful intervention for patients with severe mental illness and documented histories of poor compliance leading to repeated relapses and re-hospitalizations.”

The statement, however, recommended that the initial commitment period be no more than 180 days while the Massachusetts bill would provide for an initial period of 365 days.

NAMI Massachusetts submitted testimony on the bill in June asking that, because AOT is not a research-proven method for assisting patients in need and because there are limited services already, the legislature focus, instead, on building a “non-coercive relentless outreach, peer-led approach” that would focus on engaging and encouraging patients to accept treatment and provide family support.

Shoshana Fagen, Psy.D, a clinician with Franciscan Children’s Hospital in Brighton, Mass., has a history in advocacy work. She agreed that, in theory, AOT can be an important support for those who need it.

“The unfortunate reality is that mental illness is, in essence, a neurological condition that impacts the thought process,” she said. “As a result, there is a subset of the population who are unable to think logically and rationally about what is in their best interest without the support of specialized medication.”

When they receive treatment, she added, they can function outside of a restrictive in-patient setting. However, these people often have other difficulties in their lives, like housing or employment or transportation to appointments, and when those issues are not being handled, it can cause them to fall off their treatment plans.

“This often leads to a cycle of regular admission to inpatient units for stabilization, then discharge and falling back off their medications and then readmission,” she said.

The main concern, she added, is the fact that the current version of the bill does not address how these services would be funded.

“I always am concerned about unfunded mandates,” said Fagen, “and the bill specifically speaks to requiring treatment plans and including requirements for supervision of the meds and assistance in obtaining basic needs such as employment, food, clothing, shelter. That is all going to require funding for staffing and ensuring these patients are receiving services.”

Fagen also questioned why physicians are the only medical professionals who have the authority to petition the court for AOT.

“Not everyone who needs services needs medication,” she said. “Why is that an assumption? Why are they losing the right to decide whether or not to be medicated?”

Opponents of the bill say that forced treatment is shown not to have successful outcomes, leads to further racial disparity when Black and brown people are more often sentenced to this type of commitment, and can increase feelings of depression and suicidal ideation.

AOT can lead to a loss of individual rights, said Sera Davidow, director of the peer-run Western Massachusetts Recovery Learning Community. Laws like this are supported, she said, because people believe that those with mental health issues are more likely to be violent.

“The general public are comforted by the idea that there are certain groups who are more violent and that we can prevent it,” she said. “That is not based in research. People with psychiatric diagnoses are more likely to be the victim, not the perpetrator. There are people who are proven to be more of a risk of committing violent acts, like young white men, but nowhere is there support for taking away someone’s rights based on that actual research.”

The problem, she pointed out, is that we hear one story of a mentally ill person committing a crime and then we apply that information to all mentally ill people.

“We do not have the tools to predict human behavior,” she said. “We can argue that they are being punished for a crime before it is committed.”

While involuntary outpatient commitment may help some people, she argued, it tends to bleed over into the general population and become more and more restrictive for those who do not need it, leading to poorer outcomes for those people.

“When you make laws based on the most extreme situation, it tends to really drift into the rest of the community,” Davidow said. “In the long run, do we do more harm than good?”

That balance is the question. Will an outpatient law be too widely used or would it help fill a gap in treatment for those not receiving services?

“I believe the argument for one treatment approach over another limits choice,” said Murtore. “AOT can and should exist as one option in the toolbox, alongside community-based support and other traditional treatment options. Again, our focus is creating an AOT law to address the most severe cases where other treatment options have failed. While there is no one-size-fits-all treatment solution, AOT is a proven tool to successfully treat those fitting the narrowly defined criteria.”

The final draft of the bill, and any funding attached, remains to be seen as are the effects it may have.

“In concept, I support the bill,” said Fagen, “But whatever services are being mandated, there needs to be a comprehensive wrap-around model in order to support those services.”