I was attending a convention in San Francisco prepandemic and decided to stroll through the downtown park for lunch when I saw him. He seemed to be a healthy young man but he was rummaging in a trash can, immediately eating whatever he could find.
I was stunned, and walked over to offer to buy lunch when he suddenly spun on me with a look of rage and screamed for me to “F--- off!” I did, and bystanders kindly explained that he was one of many homeless people with mental illness who live in the park.
How can this be? Forty-seven states have passed laws enabling assisted outpatient treatment (AOT) for people with severe mental illness who, because of their illnesses, refuse treatment and become a threat to themselves or others.
All that is required is a civil court hearing to determine need and to stipulate treatment, typically medication and/or psychotherapy. As long as the recipient continues in treatment, he is free to go about his life in the community. If he ceases treatment, he will be reassessed by the court.
Substantial research shows that AOT is very effective, dramatically reducing hospitalizations, homelessness, arrests and greatly improving the person’s quality of life. So why are state and local officials not using it more?
It’s not a funding issue, since AOT actually saves money in the long run. It’s not due to resistance from family members, who invariably plead with authorities to help their loved ones find the treatment they so urgently need.
It turns out that the problem lies with government and private organizations that advocate for patient rights to nontreatment, and who therefore philosophically disagree with the premise of AOT. The AOT premise is that mandated care is the right thing to do for those whose illness prevents them from accepting the treatment they need, and who are at risk for harm to self or others.
The right-to-nontreatment advocates believe that even a psychotic person (such as someone struggling with paranoid schizophrenia) has the right to live his own experience, regardless of risk. So they seek out relevant cases, file lawsuits, and either slow or defeat AOT efforts. Over time local authorities tend to defer, worn down by costly and endless legal battles.
The right-to-nontreatment advocates are well meaning, but overlooking a basic truth. It is not compassionate to let a young man live on the street eating out of garbage cans, tormented by psychotic paranoid delusions and convinced that those around him mean to do him harm, when an AOT intervention would return him to a normal and fulfilling life.
It is compassionate to provide the treatment necessary for recovery, so that he can have the opportunity to enjoy loving relationships, have a real home and find a meaningful job — even if this requires mandated treatment.
That’s the humanitarian reason for AOT, but there also is a public safety concern. As we know, people with mental illnesses per se are not more likely to commit violent acts than anyone else. However, people with severe psychotic mental illnesses who are not in treatment are more likely to commit violent acts.
Tragically, this can be inflicted on family members, work or school colleagues or random strangers encountered at the peak of a paranoid psychotic experience. The Virginia Tech shooter who killed 32 students on April 16, 2007, is a case in point.
He was refusing treatment despite being assessed to be at risk for violence. It neither is helpful for the person in need, nor fair for the community, for right-to-nontreatment advocates to block AOT efforts through endless legal actions.
Instead, we need state authorities such as the Virginia General Assembly to pass legislation to shield good-faith AOT efforts from endless legal challenges. AOT must, of course, be carefully managed so as not to be misused or selectively applied to any group, and there must be an appeals process available for the person in need. These safeguards easily can be ensured.
The time to act is now. We have abandoned too many people to live a life of torment from their psychotic delusions, and we have allowed too much violence (up to and including mass murder) to be inflicted by them upon the community. Everyone wins if assisted outpatient treatment is allowed to do its job.
Timothy A. Kelly, Ph.D., is a former mental health commissioner for Virginia, and author of “Healing the Broken Mind: Transforming America’s Failed Mental Health System”. He is chief of the behavioral health department at SinoUnited Health Clinics in Shanghai. Contact him at: email@example.com