Among the many shortcomings of the nation’s mental health care system is its inability to address a core conundrum: how to help patients who do not think they need help and who refuse treatment?
That question is at the heart of the worst side effects of mental illness — violence, suicide, and homelessness — and yet it is difficult to address because of laws meant to protect individual freedoms and inadequate mental health care infrastructure.
Adam Howe, 34, who killed his mother, Truro resident Susan Howe, 69, on Sept. 30 and then himself, suffered from bipolar disorder and psychosis. Off and on for at least two years, these conditions had made him a danger to himself and others — a conclusion that would have enabled a judge to commit him to a psychiatric hospital against his will under Section 12 of state law.
The law allows such hospitalizations for up to 72 hours. The problem is that these so-called involuntary holds often fall far short of the goal of treating patients so they can safely return to home and community, according to Mary Zdanowicz of Eastham.
Zdanowicz was the founding executive director of the Treatment Advocacy Center, a nonprofit with a national reach based in Arlington, Va. Now retired, Zdanowicz is a board member of the National Alliance for Mental Illness (NAMI) Cape Cod, a nonprofit advocacy organization that provides education and support to those with mental illness and their families and friends.
Adam Howe was familiar with the courts and psychiatric hospitals. In November 2020, Vermont police responded to an emergency call when Howe threatened to kill himself at the home he shared with his wife, Aliey Hogan, and their infant daughter, according to the Boston Globe.
Though police took him to the Rutland Regional Medical Center, he was released the following day when hospital staff determined he was “no longer a danger to himself, and the facility was unable to keep him against his will,” the Globe reported. Hogan and other Howe family members did not return calls from the Independent before the newspaper’s deadline.
The following year, police in Vermont arrested Howe again for domestic violence. After his death, Hogan told the Globe that when Howe took his medication “he was … the best person I’ve ever known in my entire life. When he was off his meds, and especially when he was drinking, he would go into psychosis.” During those episodes, she said, he was convinced “everyone was out to get him.”
What’s clear is that Howe suffered from anosognosia, a condition associated with dementia, schizophrenia, bipolar disorder, and psychosis. It refers to a lack of insight that makes people resist treatment — and which, in turn, can lead to devastating consequences including “homelessness, jail, suicide, and, although we don’t like to talk about it, violence,” Zdanowicz said.
The activists who founded the Treatment Advocacy Center in 1998 hoped to address anosognosia, said Zdanowicz, an attorney whose brother and sister have schizophrenia.
When she was at the Advocacy Center, Zdanowicz said, she talked with many mothers who struggled to help their children as Susan Howe must have. “This is a very common problem,” she said, “and it has only gotten worse.”
Jackie Lane, executive director of NAMI Cape Cod, agrees. What her organization has found trying to reach mentally ill homeless people in Hyannis is that, for many who refuse help, “their families have just given up.”
In Lane’s view, laws designed to protect civil liberties can be a problem. Massachusetts in particular, she said, has strict laws protecting people’s rights to make their own health-care choices, even if those choices end up killing them or others.
The Section 12 Process
There is a process for getting a loved one into treatment against his will in Massachusetts. It begins with obtaining a Section 12 order from a judge. The police, a doctor, or a family member can ask to have a person taken to an emergency room under Section 12.
At the emergency room, a psychiatrist can order an additional stay in a short-term care facility like the 20-bed psychiatric care unit at Cape Cod Hospital.
While the involuntary hold lasts only three days, clinicians may be able to persuade a patient to remain for a few more days. But according to Zdanowicz, it is unlikely that the patient will stay long enough for a doctor to see if medications are working and to ensure there is outside support once the patient leaves.
Howe never stayed longer than one week in all his psychiatric hospitalizations, the Globe reported.
After decades of mental hospital closures, most of the psychiatric beds in Massachusetts are for short-term care, Zdanowicz said. They provide stabilization but not treatment. The goal of the closures was to keep people out of institutions, but it has left people with no alternatives, Zdanowicz said. There has been no advent of community-based treatment systems.
Lane has seen many cases of anosognosia in adults whose parents are trying to provide some semblance of care at home. “It is really tricky to help someone unless they agree,” said Lane. “And if they are off medication, they are not going to agree.”
Lane described a situation faced by a family NAMI Cape Cod is trying to help in Eastham. In that case, a mother is living with her son but is afraid of him. She locks her bedroom door at night. NAMI has advised her to get a restraining order against him, Lane said.
“For a mother to throw her son out on the street — that is very difficult to do,” she said. “But these people are very manipulative. At some point you have to decide, ‘Will I live in danger or not?’ ”
“My opinion, probably not popular,” added Lane: “We should have mental institutions so there are more beds.”
Assisted Outpatient Treatment
Short of revamping the nation’s entire mental health care system, there is one legal shift that could make a difference by giving more power to the state in treating people who have anosognosia.
Called the Assistant Outpatient Treatment (AOT) law, it enables judges to order patients with severe mental illness and histories of noncompliance, jail time, or hospitalizations to take medications and adhere to treatment plans. The treatment organization Zdanowicz worked for has helped pass it in all of the states but three: Connecticut, Maryland, and Massachusetts.
One of the staunchest opponents of the AOT is Mass. Secretary of Health and Human Services Marylou Sudders. She has opposed it since the 1990s when she was the state’s commissioner of the Dept. of Mental Health.
Sudders’s argument is that placing legal obligations on the mentally ill only increases the chances they will end up on jail or in emergency rooms, according to the State House News Service.
Sudders has pointed out that when New York passed its version of AOT, known as Kendra’s Law, the state authorized more than $120 million in funding support to make it work. As it stands in Massachusetts, there are not enough services to enforce mandates and provide treatment.
Emergency rooms here are vastly overburdened. The Mass. Health & Hospital Association found that, in September, 697 behavioral health patients were “boarding” — that is, stuck in emergency rooms awaiting treatment beds, and that 20 percent of inpatient psychiatric beds are “offline” because of staffing shortages.
Patrick Kane, senior vice president for communications at Cape Cod Hospital, pointed the Independent to that MHHA data, but after follow-up emails throughout the week, Lisa Connors, the hospital’s manager of marketing communications, said the hospital could not provide an update on the status of the 20 beds in its psychiatric unit in time for the newspaper’s deadline.
With no alternatives, those living with the mentally ill are left to call on the police when a crisis occurs.
NAMI Cape Cod holds regular crisis intervention team training for police officers. The 40-hour courses mean devoting a week to classes. The last session just ended but no one from the Outer Cape could attend, said Lane, because the its police departments did not have sufficient staff to spare an officer.
Editor’s note: An earlier version of this article, published in print on Nov. 10, misspelled the first name of Adam Howe’s wife, Aliey Hogan.
