When Nick Craciun was 17, he began exhibiting signs of psychosis. At 20, he disappeared from home. He told his parents he was living at a friend’s house. By the time he turned up, he had spent two wintry months living in his car, says his mother, Laura Craciun of North Truro.
Since then, Nick has been hospitalized four times. On Dec. 27, 2023, in a bout of delusion, Nick attacked his father, who lives in Cambridge. The police came, and since then Nick has been shuttled between hospitals and correctional facilities. He is currently incarcerated in the regular population at the Middlesex County Jail.
Nick has been diagnosed as bipolar 1 with psychotic features including paranoid delusions and with schizoaffective disorder. As far as Laura knows, Nick has been on medication just once — because of a judge’s involuntary commitment order — for five weeks at McLean Hospital in 2022. The judge ordered Nick to follow up monthly with a doctor, Laura said. When he didn’t, there were no repercussions.
Laura said she can’t count the number of times she’s tried talking to Nick about taking anti-psychotic medications: “I couldn’t tell you,” she said, comparing it to “the number of stars.”
Massachusetts is one of just three states — the others are Maryland and Connecticut — without assisted outpatient treatment (AOT) legislation. Those laws allow caregivers of people diagnosed with one of a list of Serious Mental Illnesses (SMIs) to petition a civil court to require that their loved ones be medicated.
Maryland is close to enacting a law; as of April 8, an AOT bill had passed both houses of the state legislature.
A bill to allow AOT in Massachusetts faces less certain prospects, however.
“An Act to Provide Critical Community Health Services” (S.980/H.1694) is currently in the Joint Committee on the Judiciary. In addition to having a listed SMI, a person must have had at least two hospitalizations (or mental health services visits in correctional facilities) in the previous 36 months to be eligible for a court-ordered treatment plan, which could include medication and therapy.
The bill is controversial. Advocates argue that it would prioritize necessary mental health treatment and decrease the criminalization of mental illness, while opponents warn it would infringe on civil liberties.
“When it comes to treating those with severe mental illness, we have literally zero options,” says AOT advocate Ann Corcoran of Swampscott, director of the National Shattering Silence Coalition. “You have to wait until someone becomes dangerous before you can get them help.”
The Mass. branch of the National Alliance on Mental Illness (NAMI) submitted written testimony last July opposing the AOT bill. The testimony, provided to the Independent by Deputy Director of Programs Eliza Williamson, recognizes the challenges of treatment refusal but still comes down on the side of patients’ rights.
“It is of the utmost importance that people living with a mental health condition are given the opportunity to exercise human rights, including the right to make complex and multi-layered decisions about their own healthcare,” the testimony reads. “There are many, many stories about the trauma experienced by individuals living with a mental health condition when they are subjected to involuntary treatment, or AOT.”
But NAMI Cape Cod and the Islands, the organization’s local chapter, supports the legislation, according to Executive Director Jacqueline Lane.
A cancer patient who refuses treatment is “probably qualified to make a decision about their own health,” Lane said, “while a person who is in a psychotic episode would not necessarily make that same decision if they weren’t in psychosis.”
The Mass. Association for Mental Health also testified against the legislation, citing concerns that the bill will “rely principally on force and coercion.”
Mary Zdanowicz, who founded the Virginia-based nonprofit Treatment Advocacy Center (TAC) and who now lives in Eastham, believes AOT would be a step toward improving care.
“In Massachusetts there is this assumption that if somebody doesn’t want treatment, that is their decision,” Zdanowicz said, “which sounds good, except if somebody’s brain is disordered.”
Refusing Treatment
According to TAC, 20 to 30 percent of people with an SMI also have anosognosia: a condition that prevents them from understanding that they have a brain disorder.
About 60 percent of people with schizophrenia and 50 percent of those with bipolar disorder have anosognosia, according to TAC, which leads people like Nick Craciun to resist treatment.
Ashoke and Vinita Rampuria, cofounders of AOT NOW, a Massachusetts-based advocacy organization, have watched their son suffer from an SMI and refuse consistent treatment since 2011. Now 34 years old, he has been hospitalized more than 40 times.
During this “endless cycle,” Vinita said, “there has never been a positive outcome.”
Under current law, a judge can order involuntary commitment to a psychiatric hospital for a maximum of three days.
Periods during which people with SMIs are medicated can be stabilizing, but that stops when the treatment does, said Cliff Calderwood of East Falmouth, who leads a support group for caregivers of people with SMIs. About 96 people are in the group statewide, 38 of whom are on Cape Cod.
Calderwood’s son Nigel, now 32, began showing symptoms of paranoid schizophrenia in 2011 but resisted treatment. The next six years became a “merry-go-round” of recurring psychotic episodes followed by hospital visits and brief stints on medication, Calderwood said.
Since 2017, Nigel has been medicated and “the world opened to him.” He drives and has been holding down a job at a local grocery store.
Jenna Howe, the daughter of the late Susan Howe of Truro, believes that AOT would likely have changed the course of her brother Adam Howe’s illness. On Sept. 30, 2022, Adam killed his mother at her home and a few days later took his own life while in jail.
“He had periods where he was med-compliant,” Jenna said. “During those periods, you could tell the difference, for sure. I’m OK being the worst-case scenario as long as I can help try to get the word out so that no one else has to have this happen.”
An Uncertain Path
It is unclear whether the AOT bill will move forward in this legislative session, which ends July 31. Similar bills were introduced in 2017 and 2019 but were not enacted.
The bill’s sponsors are state Sen. Cindy Friedman (D-Fourth Middlesex) and state Rep. Mathew Muratore (R-First Plymouth).
Friedman said she was driven by the lack of mental health care options for “a very small but really important subset of people. Our system can’t figure out any way to deal with their illness when it’s untreated except to criminalize it.”
Muratore’s experience with a family member who suffered from deteriorating mental health led him to introduce the legislation, according to his legislative aide Betty DeBenedictis, as did the stories of other families who have seen their loved ones go through “a vicious cycle of rehospitalizations, being homeless, harming themselves or others, and ending up incarcerated.”
State Sen. James Eldridge, cochair of the Joint Committee on the Judiciary, said he does not yet have a stance on the bill.
“I praise the authors because it’s a very narrowly drawn, tightly crafted bill,” Eldridge told the Independent. He said he is looking to organizations and advocates for how to weigh the problems of patient rights and treatment follow-through.
“We’re still reviewing the bill,” Eldridge added. “These are negotiations and discussions between myself and the House cochair.”
The House cochair of the Joint Committee, state Rep. Michael Day, “does not comment on legislation pending before the committee,” a staff member said.
Cape and Islands state Sen. Julian Cyr said that after the major mental health legislation that passed at the end of the last legislative session in 2022, “I’m uncertain if we’ll get to mental health reforms in the last few months of this session.
“My aim is for us to come back to mental health reform in the next legislative session” in 2025, Cyr said, “and AOT will certainly be part of that conversation. It’s an intriguing intervention, although disagreement among advocates does tend to slow things down. Senate President Karen Spilka has put mental health at the top of the priority list on Beacon Hill,” Cyr added, “so I’m optimistic we’ll advance another package of reforms next session.”
