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Courts are using the powerful “black robe effect” to treat severe mental illness. Should they?

On the night of April 29, 2005, Akron, Ohio, police officers found 35-year-old William Hale lying in the doorway of his neighbor’s home, not breathing, unresponsive, and bleeding from several gunshot wounds to the torso. An ambulance rushed Hale to Akron General Hospital, where doctors pronounced him dead at 10:12 pm.

The accused shooter, a man I’ll call Buddy, claimed he shot Hale in self-defense. But the Summit County Criminal Court found Buddy guilty of manslaughter and sentenced him to three years in prison.

In the years since his arrest, Buddy has been in and out of the justice system. I tagged along with his case manager, Stacie Stahl, to pick him up for a court date last August.

Buddy looks at least a decade younger than his 36 years, though he sports a goatee the same color as his close-cropped black hair. He’s about 5-foot-5 and bone-thin; he seemed to swim in the cargo shorts and T-shirt he was wearing when we picked him up at his mom’s new house in New Franklin, Ohio, about 30 minutes outside of Akron.

Vox has changed Buddy’s name to protect his privacy because he has a difficult diagnosis: unspecified schizoaffective disorder. He has a lot of delusions, beliefs that he obsesses over. When he encountered William Hale in his doorway 12 years ago, Buddy wasn’t medicated.

One of Buddy’s recurring delusions is that surgeons long ago implanted a “robot baby arm” inside of him. Last June, he stopped taking his medication, an injection called Invega Sustenna, which he’s supposed to get once a month. Buddy went to the local emergency room and told physicians he needed surgery to remove the robot arm. The doctors committed him to the psych ward.

Stahl, Buddy’s case manager, reminded him that when he went to the ER, he told doctors about the robot baby arm.

Buddy cut her off. “But it still don’t mean a motorail, which is the number one fiction science body part, should be in my body.”

He then talked to us for six minutes about the arm he believes was implanted inside him.

I tried, unsuccessfully, to redirect Buddy, to interview him about his illness and his treatment. Specifically, I wanted to talk about how after his last hospitalization, he became part of a program called the New Day Court. It’s the centerpiece of Summit County’s “assisted outpatient treatment” (AOT) program. AOT is, essentially, court-ordered outpatient treatment.

The United States has long struggled with how to care for citizens with severe mental illness. Just a few weeks before his assassination in 1963, President Kennedy signed the Community Mental Health Act, a law that began the process of deinstitutionalization. At the time, new advances in psychopharmacology led physicians to believe that they could effectively treat the mentally ill in the community, rather than in mental hospitals. That law did not include long-term federal funding for community mental health centers, and in 1981, President Reagan signed legislation that transferred responsibility for caring for those with mental illness to the states. It included a state block grant program, but federal funding for those grants has declined significantly over time.

Today, a lot of mentally ill patients end up in prison, in jail, or homeless. One recent study found that more than half of all inmates, and about a quarter of the homeless population, suffer from mental illness — a striking public health and humanitarian failure that carries a significant financial cost in terms of incarceration and medical care.

Summit County believes AOT is the solution. While the scientific research on AOT is limited and mixed, Summit County is one of many communities that have implemented this program. A handful of studies support its efficacy, and that data was convincing enough for the federal government: One of the last pieces of legislation President Obama signed before he left office included millions of dollars to spread the AOT model all across the country.

But the model is controversial, because it involves force. And a lot of psychiatrists believe that means it will never work in the long term.

I went to Summit County because a number of psychiatrists and mental health advocates told me AOT is the best option for patients with severe mental illness. I left with some hope — and with a lot of unanswered questions about the best way to treat this population.

How the New Day Court uses the “black robe effect” to get patients to take treatment seriously

Even before Akron built a unique model for treating patients with mental illness in the criminal justice system, it had a longstanding tradition of taking mental health seriously. Robert Smith, known as Dr. Bob, held the first Alcoholics Anonymous meeting at his home in Akron in 1915.

In 2000, the Akron Police Department started the first crisis intervention team in Ohio, training officers to recognize mental illness and deescalate situations that involve these patients. A few years later, Akron started the state’s first mental health court, with the goal of diverting defendants with mental illness from incarceration into treatment.

The New Day Court is a different kind of specialty court, housed in the Summit County Probate Court, part of an imposing brownstone complex in downtown Akron. As we walked in, I asked Stahl about Buddy’s illness. He seemed quite sick to me, but Stahl, who has worked with Buddy for five years, said she’s seen him much worse. When he doesn’t take his medication, she said, the delusions are nonstop.

“You can’t redirect him from that conversation, and it’s just constant,” she explained. “He loses sleep. It’s really sad, actually. With the meds, he still talks about it, but it’s not first and foremost.”

Judge Elinore Marsh Stormer is the reason Buddy has been staying on his medication. She has been a fixture of the Summit County justice system for decades, including 26 years on the bench. She has an open face and warm brown eyes, and she keeps her gray curls short, a no-nonsense hairdo that reflects her demeanor in the courtroom.

Before I started in journalism, I worked frequently with judges, and in my experience, Judge Stormer is unique. Judges tend to be fairly traditional, bound by precedent: They hear cases and deliver decisions much as their predecessors did. But Stormer isn’t interested in maintaining the status quo. She wants to improve it. As she told me, “People who present to court are in a moment in time where we can positively and, quote-unquote, therapeutically effect a change in their life.”

As a lawyer, Stormer watched defendants suffering from addiction and mental illness cycle in and out of the criminal justice system. She decided to run for a judgeship, and she was instrumental in starting Summit County’s first drug court.

She wanted to implement a similar model for those with mental illness, on the civil side of the court system. Before Judge Stormer’s election, Summit County had an AOT program for years, but it lacked oversight. The police would pick up patients with mental illness, usually for being a danger to themselves or others. Then those patients would be committed to the hospital to stabilize, before being released back to the street.

“They’re told, make your appointment with your psychiatrist, go see your case manager,” Stormer explained. “Some people do that — a lot of people don’t do that. So you have people who are recurringly entering the system.”

Now, when these patients are released from the hospital, they become part of the New Day Court. Stormer started the court in 2016 and chose the name deliberately. “We picked ‘New Day’ because it’s the first day of the rest of your life,” she explained. “It’s a new day for you today.”

The New Day Court functions as the centerpiece of Summit County’s AOT program. Every patient works with a team of clinicians outside the courtroom. There’s always a psychiatrist and a case manager like Stahl, someone who makes sure the patient gets to his doctor’s appointments and has food in his pantry. Stormer gets updates from the patients’ teams before she sees them in court, and she uses that feedback to monitor their progress and decide when they need to return.

Stormer believes the court visits help patients in their recovery beyond playing a coordinating role. Patients simply respond to treatment differently in the courtroom, a phenomenon she calls the “black robe effect.” It’s a phrase I heard a lot in reporting this story.

The patients know the judge — the person in the black robe — deserves respect.

From the patient’s perspective, Stormer said, the judge is “imbued with a societal and cultural halo that you’re trying to use to say, ‘Let’s move you forward.’ Just having to come before a person in authority makes a huge difference for many, many, many people.”

At any given time, there are usually around 65 patients committed to the New Day Court. They see Stormer at different rates, depending on their progress: Some come in every two weeks, others every few months. The court meets every other Wednesday afternoon, in a courtroom that looks like an average Law & Order set: wood-paneled, with tiers of seats facing a raised bench. That’s where Stormer sits, flanked by the American flag and the state flag of Ohio.

The court is unique in this respect: Every other Wednesday, all the patients due in court that day gather in the courtroom together. They watch as their peers go up before Judge Stormer, one by one. This is part of Stormer’s treatment philosophy: The ones doing well go first, and the ones having trouble appear later. The new patients go last, so they watch everyone before their names are called.

The day I visited, I sat next to Stormer on the bench and she wrote notes to me as the patients came up (I’m not using their names to protect their privacy). One of the first people called — one of the patients doing well — was a woman who looked to be in her late 20s. She was dressed casually, in jeans and a T-shirt, with her messy brown hair pulled back in a loose bun. As she walked up, Stormer scribbled to me, “Tried to commit suicide three months ago.”

The woman seemed a little uncertain — she clasped and unclasped her hands as she stood before the bench — but she responded to Stormer in a loud, clear voice. Stormer congratulated her on enrolling in school for her associate’s degree — “I think that’s atremendously positive step forward,” she said. She also asked after the patient’s kids.

“Did you go to the movies?” Stormer asked. She often rewards patients with movie tickets.

“Yes, we did. We saw The Emoji Movie. In fact, it inspired them, and they both wanted Emoji Movie backpacks for back to school,” the patient replied, smiling. “It was the movie they wanted to see the most, so that’s the movie we went to see. And thanks to you, they were able to see it.”

Stormer shook her head. “Well, no, thanks to you.” She shuffled her papers. “So I will see you sometime toward the end of September.”

A few more success stories came up — I watched one patient blush at a round of applause, and two more picked up movie tickets. Then Stormer started to call the patients who were still struggling. Buddy approached the bench with Stahl about three-quarters of the way through the afternoon. Stormer asked him about a hernia surgery he was about to have — a real surgery, one he actually needed — and Buddy jumped at the chance to ask her a related favor.

“I’d like to have a law enforcement officer next to my bed — somebody who works for the state and knows all the human body parts so they don’t try to do anything stupid.” Buddy shifted his weight from foot to foot as he stood in front of the bench. He seemed to radiate anxiety, likely connected to his delusions about doctors and surgeries.

Stormer noticed it too. “I can’t do that,” she said, “but what I can do is make arrangements for you to get records. Would that make you comfortable, if we get your records?”

“Why wouldn’t I be able to have someone by my bed, in case they break laws—”

“Because they cost 20-something bucks an hour,” Stormer replied.

Buddy whistled. “Damn,” he said.

Stormer tried to relate. “Yeah, I know. Generally speaking, you don’t have to worry about them doing anything during these surgeries, but if you’re concerned about it, we can always get your records afterward.”

Buddy agreed. But he had another question.

“Is there any way I can discontinue having to take shots, because they don’t do anything for me.”

“Not right now,” Stormer said. “I’ll tell you what, I think the shots are working.”

Buddy laughed.

“I’m telling you, you look so much better! You were all over the place when I first met you.”

“I was in deep zone, huh. Deepville.”

“Yeah, wherever. You weren’t exactly here with me. So today, I feel like we’re having a really good chat.”

But Buddy wasn’t satisfied. He kept asking for a “deadline” to go off the medication. Stormer finally shut it down. “Let’s get through the surgery; let’s get things settled down. One step at a time.” She punctuated this last sentence by slapping her desk.

This appeared to be the black robe effect in action. Buddy respected Stormer. He listened to her, even if he didn’t like her pronouncements. Stormer knew not to challenge his delusions, but she didn’t indulge them either. She found a tailored solution to his paranoia: seeing the records. That really did seem to calm him.

I was impressed. But then one of the last patients of the day came up to the bench. It was her first time at the New Day Court. She looked to be around 50 years old and wore her gray hair in two braids down her back. She kept her hands in her pockets as she talked to Stormer, who asked after her five children.

“The two oldest are with their dad, the third one is with his dad, the fourth one’s with my sister, and the fifth one’s adopted.”

“And you’re on birth control?” Judge Stormer asked.

“No.”

Judge Stormer’s eyebrows shot up. “Oh, no?”

“No. I’ve got two grandsons, and I’m celibate, so I don’t think anything’s going to happen.” The patient giggled.

“Well, you never know.” Judge Stormer laughed. “They have long-acting birth control now. They just give you a little shot. You don’t need any more kids on your list right now.”

I was troubled by this exchange. It might be in this patient’s best interest to go on birth control, but a judge telling her that gave me pause. The idea that the courts might dictate who gets to have children and when reminds me of some of the worst moments in our country’s history.

For instance, between 1907 and 1937, 32 states passed sterilization laws designed to rid American society of “undesirable” traits. The 1927 Supreme Court case Buck v. Bell, which concerned a plaintiff classified as “feeble-minded” by her home state of Virginia, upheld the right of a state to forcibly sterilize a citizen considered “unfit” to procreate.

And yet the New Day Court is not an average courtroom. It functions as a hybrid space, with lawyers, social workers, and doctors all working together.

But thanks to the black robe effect, these patients see Judge Stormer as the ultimate authority. She has a different kind of influence, something bigger, even more powerful than the guidance of a doctor or social worker.

“She actually paid attention to what I was saying, and she moved to help me in any way she could”

After the court session, I met Sean Walker, a patient who’d graduated from the New Day Court under Stormer. She’s 38 years old and wears her hair in an Afro; the day we met, it was held back with a navy bandana. Like Buddy, she didn’t dress up for court: she wore cargo shorts, a T-shirt, and tennis shoes. What stood out, though, was her jewelry. She makes it herself: earrings with copper beads and feathers, connected by bronze chains between the holes in her lobes. They jingle when she talks.

Walker began by telling me about her extraordinarily difficult childhood. Her mom was addicted to drugs and physically abusive. She lived with her grandparents for a few years, but eventually became a ward of the state. At the age of 15, she was diagnosed with schizoaffective bipolar disorder and psychosis, a disease that gives her delusions, like Buddy, but also other symptoms such as mania and depression. She started taking medication.

I asked her when she had managed to accept her diagnosis, and she let out a long, heavy sigh.

“To be truthful, I still don’t accept it,” she told me. “I know where I came from. I know who I am. If they have to put a label on it so they can better categorize it and understand it, then [okay] if that’s what makes them feel better.”

After she turned 18, Walker lived on her own for years. But eventually she stopped taking her medication, and her mental health deteriorated. She ended up in the hospital, and she remembers those months as some of her most difficult. “It’s like being caught in a mudslide and anything you reach for gives,” she said. “It’s like drowning.”

Last year, she entered the New Day Court for the first time. “It was like armor on, dukes up,” she recalled. And while Stormer “was very nice from the get,” at that point, Walker recalled thinking, “I don’t want to listen to anybody because nobody’s listening to me.”

Eventually, after a few court visits, Sean realized that she could trust Judge Stormer. “She actually paid attention to what I was saying, and she moved to help me in any way she could,” Walker recalled. “So, slowly but surely, the ice melted.”

Walker has also seen a change in herself, compared to who she was when she first encountered Stormer. “I’m not as enraged. The anger is still there, but it’s not seething,” she told me. “I have a right to be angry, but there are still choices. Am I angry? Yes. Am I going to go out and do something that’s going to get me in trouble because I’m angry? No.”

Walker says her art — the jewelry-making and painting — helps her cope, as does writing in her journal and taking long walks in the park. She also sees a psychiatrist, though she wrinkled her nose in disgust when I asked her about medication. I asked if she has to get injections, like Buddy. Her eyes widened.

“No shots. I’m not agreeing to that. At least if the medicine isn’t going right, you can stop taking the pills. If you take a shot, it’s in for the duration. So you got to ride it out.” She shook her head, earrings plinking.

I asked if she takes her medication every day.

She paused. “Yeah,” she said into my tape recorder — while looking me in the eye and shaking her head “no.”

This really surprised me. The New Day Court handpicked Sean to speak with me. She’s a graduate of the program, and yet she doesn’t take her medication every day.

Why some psychiatrists don’t see AOT as the best solution

Apparently, this is common among patients with psychotic disorders. I talked to Dr. Irene Hurford, a psychiatrist and assistant professor at the University of Pennsylvania. She treats patients with severe mental illness, and I told her about my interaction with Walker.

“There’s a wish to look better — healthier, happier — to the people that are kind of responsible for getting you that way, than you really may feel,” she told me. Walker might not want to disappoint Stormer, an authority figure committed to helping her.

Hurford sees this a lot in her own practice. “I have people that I really think I have a good working relationship with and I really believe that we trust each other, and it will come out — either I’ll check a blood level, or they’ll tell their therapist, or their parent will call me up and say, ‘Did you know that he’s not taking his medication?’ And I’m like, really?”

In addition to her research at Penn, Hurford manages an outpatient program for patients with psychosis in Philadelphia. She’s very familiar with the myriad problems in the way we treat patients with severe mental illness in this country: “The way the system usually works is like a baffling ordeal, and I hope that you never ever have to confront it.”

But Hurford doesn’t think AOT is the best solution — or that it works in the long run. She said effective treatment relies on trust. If she forces a patient into treatment, that trust is broken. That’s especially problematic for patients who suffer from delusions, because they may fully believe in an alternate reality.

When these patients finish forced treatment, they may recognize that they needed help. But Hurford said the delusion doesn’t fully retreat, and neither does the terror of not being believed by their doctor, the person whose job it is to care for them. Hurford said it takes a long time for her to rebuild trust when she has to force a patient into treatment. Sometimes it’s just gone for good.

To Hurford, the ideal treatment regimen is the one she started in Philadelphia. It’s an outpatient program for patients who have just suffered their first psychotic episode, right at the beginning of their illness. It’s a dedicated team approach, including therapists, doctors, education specialists, family therapists, occupational therapists, and more. The team works together to support the patient and his or her goals.

This approach sounds ideal — and rare. While the federal government has started grant programs to fund this model, such programs are few and far between.

Meanwhile, in Summit County, most of the doctors and case managers I met said their patients would probably be in the hospital or in jail if they hadn’t ended up in AOT. Hurford agreed, but also wondered why the same resources provided to the patients in AOT couldn’t exist without the court involvement.

“It is also almost certainly true that there are people in that program who could be doing just as well if they had the same resources but without the coercive aspect,” she said.

“Nobody agrees on what the data [on AOT] actually mean”

The data doesn’t necessarily bear that out. Dr. Paul Appelbaum, a professor of psychiatry and law at Columbia University Medical Center, has studied the research on AOT. So far, there have been three controlled trials of AOT, but, he says, “nobody agrees on what the data actually mean.”

He did single out one study — not a controlled trial, but research that he believes to be the highest quality available. The researchers looked at New York state’s AOT program and compared patients in AOT to patients who have intensive services without a court order. The group with the court order was more likely to stay in treatment and much less likely to be hospitalized.

It’s studies like this one that influenced members of Congress. They decided to include millions of dollars in funding for AOT programs in one of the last pieces of legislation President Obama signed before he left office, the 21st Century Cures Act.

The AOT provision was part of the Helping Families in Mental Health Crisis Reform Act, championed by then-Rep. Tim Murphy (R-PA). Murphy was in the news in October for other reasons. The press uncovered an affair and an abortion scandal, and then Murphy decided to resign. I talked to him before that, when he was still primarily known as the only practicing psychologist in the federal government.

Murphy was also a major advocate for AOT. He secured federal funding for the program in 2014, a pilot project that included $13 million for 17 communities across the country to set up AOT programs. The legislation signed by President Obama included millions of dollars more, to be distributed through 2022.

Murphy wasn’t just convinced by the studies. He told me that his experience treating patients with severe mental illness led him to see these patients in a particular way.

“I work with people with schizophrenia and bipolar illness, and when they are in the throes of their illness, it is a qualitatively different way of viewing the world, when they are caught up in their delusions,” he explained.

I interviewed him with another reporter, Sarah Kliff, who followed up on some of Dr. Hurford’s concerns. She wanted to know how Murphy would decide when a patient has to be committed.

“Where is the line of when it’s okay to take away that liberty?” Sarah asked, “And say, you know, you need to go into treatment—”

Murphy cut her off. “You keep harping on the liberty, and I’m telling you, it’s different. If a person doesn’t even know what planet they’re on, what liberty are you talking about?”

That’s why the judge is there, he explained. “A judge is there to protect their rights; a judge is there to make sure they’re not abused by the system. And so that is built into the system, that their civil liberties are protected, while at the same time being aware of the cognitive limits that they have in the throes of their severe mental illness.”

That leaves a lot up to the judge.

When I talked to Hurford, I told her about some of Stormer’s successes in the courtroom. She told me that I had “walked into a wonderful courtroom with an exceptional judge.”

By the same token, Hurford herself is an outstanding caregiver with a well-funded, full-service program for her patients.

But not every judge is Elinore Marsh Stormer, and not every psychiatrist is Irene Hurford. And as these practitioners strive to translate their exceptional experiences into public policy blueprints, I wonder: Are they letting the perfect be the enemy of the good?

We’ve failed this population for too long

The data we have on AOT is mixed, but it does work for some patients. Buddy seems to fall into that category. I followed up with Stormer about six weeks after my visit and asked her about Buddy’s surgery. She told me it went well, and that Buddy seemed “very calm” about the procedure.

“He didn’t seem focused on that paranoia that people were going to do other things to him, or implant things,” she said. “He’s much more focused on his own present life than concerned about a multitude of other paranoid fixations that he had previously,” she went on. “So that’s progress.”

It is progress — but how long it lasts is another question. I also followed up with Stahl, Buddy’s case manager, and I asked her if she thought Buddy as I saw him might be Buddy at his best.

She laughed. “Yes, I’ve had him for years. And this is just how he’s always been.”

I wondered if Buddy might never get his injection voluntarily. While Stormer can’t order the injections indefinitely, Stahl agreed that Buddy wouldn’t do it on his own.

“Before this New Day Court, where he would be ordered to have injections, he would have them only as long as he was ordered,” she said.

Patients with diseases like Buddy’s often have their first psychotic episode in young adulthood. It’s a critical time to get care. The World Health Organization urges patients to seek treatment within the first three months of their first episode. But in the United States, that seems like a luxury: a number of studies have found that patients have, on average, a gap of one to three years between their first psychotic episode and their first treatment. That causes long-term damage.

If Buddy had had access to a program like Hurford’s when he first got sick, maybe he wouldn’t have needed to be forced into treatment. But he didn’t. Most patients still don’t.

This population has suffered for so long. We’ve failed them, time and time again. So maybe the best we can do for them in the long term is to advocate for programs like Dr. Hurford’s — while compelling them into outpatient treatment in the meantime.

Vox

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