When Ashoke and Vinita Rampuria’s son returned home after taking a year off from college, to complete his course work, he didn’t seem like himself.
"He was unable to complete tasks. He was lying on the sofa," said Ashoke Rampuria, a resident of Acton, Massachusetts. "He took some jobs, but could not hold them."
In 2011, his son was diagnosed with what Rampuria described as a severe mental illness. He soon began cycling in and out of health care facilities, appearing to get his illness under control and then slipping back once released. In 2021, the couple said their son used a new medication and was able to hold a job for three months, but did not continue on the drug.
All along, Rampuria said he and his wife lacked a crucial tool – the power of a judge to order their now 36-year-old son, currently at a psychiatric hospital in Lynn, Massachusetts, into mandatory outpatient care.
Massachusetts, along with Connecticut and Maryland, are the only states that don’t give courts that authority.
"This is a revolving door. They will send him to a hospital for a while, then they will release him and if he doesn’t take his medicine, he will be back," Rampuria said. "If our son could stay on the treatment continuously for a year, he will achieve what he wants to achieve, to hold a job and live independently."
A bill before Massachusetts lawmakers would let family members and mental health professionals ask courts to order outpatient mental health care for adults with a persistent mental illness and significant history of serious physical harm to themselves or others.
The court would be allowed to order a personalized treatment plan, including a monthly assessment by a mental health professional to see if the person should remain in court-ordered community treatment, according to the bill’s author, Democratic state Sen. Cindy Friedman. The bill is still in the very early stages of making its way through the Legislature.
Friedman said the legislation relies in part on what she called the "black robe" effect — the idea that a treatment plan ordered by a judge is more likely to be followed through by the patient. She also dismissed criticism that mental health care should only go to those who seek it.
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"You don’t solve the not enough treatment problem by denying people who need treatment, treatment," she said. "This is about a very specific subset of people who don’t know how sick they are."
Friedman said there can be potentially tragic consequences when the state lets the severely mentally ill fall through the cracks. She pointed to the 2018 stabbing death of a medical student at a public library in Winchester, Massachusetts, by a man who had been diagnosed with schizophrenia in high school and was later hospitalized multiple times due to his mental illness.
He was found not guilty by reason of insanity in 2021.
Other states have also grappled with the issue, driven in part over concerns about homeless people who have a mental illness.
California Gov. Gavin Newsom, a Democrat, last year signed legislation to create new "Care Courts" aimed at forcing those with mental health issues off the street and into treatment. In Oregon, some lawmakers have pushed to expand the ability to force people into mental health care.
In New York City, Democratic Mayor Eric Adams announced in November that he wanted police and city medics to more aggressively get severely mentally ill individuals off the streets and subways, and into treatment.
In Connecticut, Republican state Rep. John Piscopo proposed a bill this year that would have let probate courts order individuals with psychiatric disabilities or substance use disorders into an involuntary medical evaluation and assisted outpatient treatment. The bill failed to get enough support.
"It’s a very, very small population that would require this and I don’t understand the advocates' opposition," said Piscopo.
Some individuals with mental illness don’t have the cognitive ability to follow through with treatment, while others don’t recognize that they have a disability, according to Lisa Dailey, executive director of the Treatment Advocacy Center, a national non-profit aimed at eliminating barriers to treatment for people with mental illness.
"You want someone to remain stable a long enough amount of time to realize they do better with treatment and continue that on their own," she said. "Research shows that it takes six months to stabilize on medication and no one is staying anywhere near that long in a hospital."
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But critics say forcing anyone into mental health care can backfire. They say the mentally ill already face a range of risks.
There are other strategies that are voluntary, from peer-to-peer counseling to creating spaces where people can talk about their struggles, according to Sera Davidow, director of the Wildflower Alliance, a non-profit that opposes mandated outpatient care.
"People who want resources can’t get them and people who don’t necessarily want them are being forced," she said. "Both of those are harmful."
Eliot Olson, a Connecticut resident who is also opposed to mandatory care, said as a high school student he struggled with depression and was given an ultimatum to accept mandatory outpatient care or leave school.
"I didn’t want to be there. Everyone else I was with didn’t want to be there. There was just a huge lack of understanding and empathy," said Olson, 30, who works for the non-profit PeerPride, which focuses in part on addressing homelessness in the transgender community.
Olson said he was in the program for about six months when the school recommended he be institutionalized. His mother refused, he said.
"I wasn't going to participate in something I didn’t have a choice in," he said.
In Boston, a voluntary treatment program aims to help individuals with a major mental illness, who have a pending criminal case or are on probation. Started in 2020, the Boston Outpatient Assisted Treatment initiative has served 165 individuals with 33 successfully completing the program.
Massachusetts Gov. Maura Healey, a Democrat, said she welcomes the ongoing debate about access to mental health care.
"It’s really important that people have access to the mental health care that they need and also that we balance individual rights in the process," Healey said.
