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The Texas Judge Who Orders Patients to Take Their MedsOscar Kazen is a pioneer in court programs that focus on treating people with mental illness

By Shannon Najmabadi, WSJ  March 31, 2024

SAN ANTONIO—Standing outside an old state psychiatric hospital in ostrich cowboy boots and jeans, Oscar Kazen doesn’t look like a judge about to walk into court.

He zips on his black robe, settles into a makeshift courtroom in the hospital basement and prepares to make the same pitch to three people in, or who have been in, the hospital after a mental-health crisis.

“Do you want to get out of that hospital? I can do that,” Kazen says, but “you gotta promise me three things: 

“One, you’ll always be honest with us.”

“You’re always gonna show up.”

And three: “I just want you to keep taking your medications, man. The whole way through. Now if you’ve got problems with the medications, we’ll talk about it.”

Kazen, a jovial 61-year-old, is a pioneer in this kind of court-supervised treatment, which is designed to help people with the most severe mental illnesses who have already been jailed or treated in emergency rooms several times.

He typically encounters them after they have been detained in hospitals, considered to be a danger to themselves or others.

For these people, Kazen says there are few long-term options, as a decadeslong push to deinstitutionalize has closed old mental hospitals and left people waiting months or years for a bed to open up. 

It is either help them take their medication or let them go—“and I’ll see them in the revolving door,” Kazen says. 

More states around the country have adopted programs similar to Kazen’s, which are known as assisted outpatient treatment. Kentucky passed a law allowing the treatment in 2017. Massachusetts and Maryland are considering similar bills. New York has among the oldest versions of the program.

A peer support specialist, left, waits with an assisted outpatient treatment program participant before a meeting with Judge Kazen at Bexar County Courthouse in San Antonio.

Local officials and some studies have found the program is effective at reducing hospital visits. Other researchers say the real benefit comes from intensive services that accompany the civil-court order, which generally requires that participants follow a treatment plan and meet with mental-health workers. 

Supporters say assisted outpatient treatment helps people with anosognosia who, due to psychosis, are unaware they are sick and therefore unlikely to medicate themselves. 

“It is very different than denial,” said Leslie Carpenter, whose son has a schizoaffective disorder that makes him experience delusions and mania. “When you say to them, ‘Hey, you need to take an antipsychotic,’ it sounds just as dangerous to them as it would be to tell you to take insulin if you don’t have diabetes.”

Other people don’t stay on mental-health medications because they don’t like the side effects, are in denial about their illness or have trouble getting them.

The outpatient treatment program has plenty of critics: Libertarians, disability-rights groups and others say it coerces people to participate in treatment they don’t want. Other detractors say the program’s success hinges on the judges and mental-health workers involved, varies widely from jurisdiction to jurisdiction, or is less effective than just boosting resources for mental-health workers. 

“Involving a court order adds tremendous complexity, cost and stigma,” said Katie Rouse, executive director of On Our Own of Maryland, a behavioral health advocacy and education organization that promotes autonomy for people with mental-health and substance-use needs. 

“There are situations where our system does not serve people well, I think we all see that. What I would hope is that the way we approach that is we go to the person experiencing the distress and say, ‘What do you need?’” she said, rather than trying to force people to take certain steps. 

Judge Kazen believes the court-supervised treatment program works but tries to temper expectations of an easy fix.

Kazen’s program relies heavily on voluntary compliance. Someone can be hospitalized if their health deteriorates, but a judge can’t threaten them with jail time or force pills down their throat. If someone seems to be lying or not doing well, program workers will see them more or call them in for extra visits with the judge. There are about two dozen people currently participating.

The oversight of the court—a so-called “black robe effect”—is credited as a reason it works, but it is unclear if the judge’s presence encourages patients to take medication or if it mainly induces doctors and other social workers to keep following up with tough cases. 

Ashoke and Vinita Rampuria, Massachusetts residents, say the program would help their 37-year-old son, a former University of Pennsylvania computer-science student who has been hospitalized more than 40 times since 2011. He improves while taking medication—his paranoia decreases and he has been able to go to work. But once he leaves the hospital, he stops taking some of his medication and deteriorates until he is hospitalized again, they say.

“No one can get him in treatment when he refuses to take the medication,” says Vinita Rampuria, who, with her husband, has advocated for Massachusetts to pass legislation allowing the program.

Participants in the court-supervised treatment meet regularly with judges, public defenders, prosecutors and mental-health case workers. Sometimes they talk about if they are still taking their medications or if they are struggling with housing or other issues that could affect recovery. 

A program participant exits the courtroom after meeting with Judge Kazen.

Other times, the conversations take more of a tough-love approach. 

One morning in March, a woman tells Kazen she doesn’t have to participate in the program and refuses to take a drug test. Caseworkers are worried she has started to use meth again; substance abuse often accompanies mental illness.

“I can walk away right now,” the woman says.

“Yeah, you could,” Kazen responds.

To read the original article in the Wall Street Journal, please click here:


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