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Dr. Jhilam Biswas

Director, Brigham and Women’s Hospital

Psychiatry, Law and Society Program

A missing link in Massachusetts mental health law

In October, there was yet another tragic story of a desperate family trying to get help for a loved one who reportedly had untreated mental illness that allegedly resulted in a murder-suicide in Truro. Adam Howe, a man with serious mental illness and substance use disorder, allegedly killed his mother and burned her body in her front yard. Two days after his arrest, he committed suicide in the Ash Street Jail in New Bedford while the courts attempted to send him to a forensic hospital. Howe’s wife described him as “the best person,” but “when he was off his meds, and especially when he was drinking, he would go into psychosis. [He’d think] that everyone was out to get him.”

Tragedies involving mental health issues highlight some of the technical nuances in Massachusetts laws that have long been overlooked by the Legislature. For example, there is no law that provides supervised and well-resourced treatment in the community for individuals who lack self-awareness, do not adhere to treatment, and exhibit persistent violent behaviors.

This lack of insight into one’s illness is called anosognosia, and is an acute symptom of psychotic and manic illness. This symptom is the largest reason for lack of adherence to treatment. When this lack of insight results in violent and unpredictable behaviors, caregivers and treatment providers require more help from the courts to keep the mentally ill individual safe. Forty-seven states have passed an Assisted Outpatient Treatment law that connects courts and community providers and has shown to reduce the revolving door of criminalization and homelessness of the mentally ill.

In Massachusetts, sweeping mental health care legislation called The Mental Health ABC Act, Addressing Barriers to Care was signed into law by Governor Charlie Baker in August. The law aims to reduce barriers to access mental health care. While this is a substantial advancement in behavioral health care, the law does not cover court-ordered assisted outpatient treatment, which provides services in the community and reduces periods of untreated illness that may render the patient even sicker in the future.

Research from the Treatment Advocacy Center, a national nonprofit focused on advocating timely psychiatric treatment for seriously mentally ill individuals, demonstrates that such programs reduce hospitalization, jail time, homelessness, and victimization for people with long histories of relapsing illness. The law also helps families who are desperate to find help for loved ones. While assisted outpatient treatment supervises the patient’s treatment, it also allows individuals to live in their neighborhoods rather than in jails, prisons, or hospitals, and regain the ability to choose treatment once stabilized.

All states except for Massachusetts, Connecticut, and Maryland have enacted laws that make assisted outpatient treatment possible. However, the quality of these laws and their implementation varies by state. The laws differ in who can petition the court, the duration of therapy allowed, and hospitalization criteria. Legislators should pass the assisted outpatient treatment legislation and encourage family participation, increase mental health court capacities, and provide enough personnel for continuous care.

Given the glaring need, the Boston Municipal Court has started an already successful voluntary program called the Boston Outpatient Assisted Treatment Program in partnership with Boston Medical Center. The program attempts to bridge the gap in stabilizing court-involved people in the community rather than in jail, with court-supervised monitoring, robust outpatient clinical care, and wraparound services. Early results are promising and show that participants are gaining access to critical health care and social services. However, the program will require future funding and current legislative support to maintain and expand its scope.

As a forensic psychiatrist who has treated serious mental illness in hospitals and in the correctional setting, I see the enormous psychological and physical trauma that patients endure in chronic untreated crises. Allowing the seriously mentally ill to remain untreated is a moral — and medical — failure when the resources, the will, and workable solutions exist. Experts in psychiatric illness, legislators, and other stakeholders need to improve the state’s mental health laws so that the resources are accessible to those who need them most.

Dr. Jhilam Biswas is director of the Psychiatry, Law and Society Program at Brigham and Women’s Hospital.

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