When someone perpetrates a mass shooting; whens someone takes their own life; when a confrontation with police ends tragically and inexplicably, we immediately wonder about their mental health history. The stubborn persistence of public violence tied to people with psychiatric disorders raises the question: Can we better prevent violent acts by mentally ill people — and better protect them from themselves — by intervening more forcefully? In other words, by forcing treatment?

Following the killings in Newtown, Conn., in 2012, legislation to reform this country’s mental health system has been moving through Congress. A central debate concerns the virtues of something called “AOT”: assisted outpatient treatment, which all sides agree is a way to compel treatment for people with so-called “severe mental illness” — like schizophrenia and bipolar disorder — who might not seek or accept treatment. Before we get to the arguments for and against, it is very important to understand what AOT looks like in action, and we’ll take New York State as an example.

In New York, the present AOT legislation is more commonly known as Kendra’s Law, after a woman who was pushed to her death in the New York City subway in 1999 by a man with schizophrenia who had been released from a psychiatric facility with little follow-up. (It should be noted that that man, Andrew Goldstein, who is still in prison for her murder, has publicly supported the law.)  The law provides that a judge can order treatment based on the petition of selected family members or treating professionals if certain criteria are met, and for a certain period of time (usually 6 months) that can be renewed. It also allows a judge to order limited hospitalization and evaluation if the person does not comply with outpatient treatment monitoring.

The main criteria for New York’s law are that a person is over 18 and has a mental illness; that he or she “is unlikely to survive safely in the community without supervision, based on a clinical determination;” that he or she “has a history of lack of compliance with treatment;” and, perhaps most familiar to the general public, is judged to require treatment to prevent a “relapse or deterioration which would be likely to result in serious harm to the person or others.”

Most states already have AOT laws aimed at getting treatment to those with severe mental illness and poor treatment adherence who pose a grave threat, usually to themselves. But compelling treatment is still a controversial idea. Rep. Tim Murphy’s bill is called the “Helping Families in Mental Health Crisis Act,” and that name tells a lot of the story. It is, at least in part, aimed at focusing mental health resources on the most severe mental illnesses, giving families more power to obtain information about and treatment for sick family members and children, and requiring states to enact AOT provisions to receive federal mental health funding.

Our friend Liza Long, who has struggled mightily with the police, courts, and hospitals while trying to care for her dangerously volatile son with bipolar disorder, is firmly supportive of the bill. She empathizes with those who worry that the law could be used to take away the freedom and self-determination of people with mental illness, she writes in a blog post following the Santa Barbara killings in 2014. But she also sees a grim future if something isn’t done for people like her son.

“The problem is that many of the sickest among us do not know that they need help. And even if they — or their families — realize they do need help,” she writes, “too often there are no resources available.” She calls for “the comprehensive transformation of our broken mental health care system” so that more Santa Barbaras and Newtowns can be avoided. “Treatment before tragedy” is her motto.

Others fault the law for allowing decisions to be made about people with mental illness without them.  “This is about helping families deal with a family member who has an apparent mental illness,” Dr. John Grohol writes at Psych Central, “not about helping the actual people with a mental illness.” He also faults the basic logic of commitment. “There hasn’t been a single study examining AOT versus treatment with AOT-level services, minus the coercion,” he writes.

This argument — between safety and self-determination, between public health and private life — is a familiar one, and a difficult one. But everyone can agree that we are in a precarious place. When state psychiatric institutions, many of them true houses of horror, were dismantled in the 1970s, it was a real victory for human rights. People with psychiatric disorders were recognized as people. But with that victory, we also dismantled a system that could have provided needed hospital beds for those of these people who are in fact desperately ill.

Now we have limited beds, limited trained professionals, and a community care model that will remain for the foreseeable future.  How we best adapt this model to help those who struggle is what Long and Grohol and everyone else are arguing about, and it is one of the worthiest and most necessary discussions to have.

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