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When courts compel mental health care, due process is crucial — but hard to ensure • Pennsylvania Capital-Star [1]
['Venuri Siriwardane', 'Public Source', 'Jaxon White', "Mark O'Keefe", 'More From Author', '- July', '.Wp-Block-Co-Authors-Plus-Coauthors.Is-Layout-Flow', 'Class', 'Wp-Block-Co-Authors-Plus', 'Display Inline']
Date: 2025-07-17 09:51:31+00:00
This story was originally published by PublicSource, an independent nonprofit newsroom serving the Pittsburgh region. Sign up for our free newsletters.
Chester tried to speak to the New York judge presiding over the court hearing that would shape the next two years of his life as a person with serious mental illness.
He was cut off by his court-appointed attorney, whom he first met 45 minutes before the hearing. “Just stay quiet,” she whispered. “The judge doesn’t like when you speak out of turn.”
Chester’s doctor had filed a petition to place him in assisted outpatient treatment [AOT] — a controversial legal mechanism for involuntary mental health treatment in the community instead of a hospital. Allegheny County told the state it would implement Pennsylvania’s AOT statute by this fall. It would be the first in the state to do so if it succeeds.
But counties in New York — where Chester lives — have been ordering people to undergo treatment in communities for years. They offer a window into what due process — the right to fair legal procedures — can look like for people facing outpatient commitment.
PublicSource asked officials involved in Allegheny County’s AOT effort to detail plans for due process and what role their respective institutions will play in providing it. It’s unclear how the Court of Common Pleas is preparing for possible AOT implementation. The county’s Office of the Public Defender — already overburdened — is training staff to boost its capacity to cover involuntary commitment hearings.
And the county’s Department of Human Services, which is behind the push for AOT, said it’s convening a working group to discuss due process, among other issues around implementation.
Chester’s experience speaks to the challenges around due process in involuntary mental health proceedings. It also raises questions about the resources state and local governments devote to the systems and institutions charged with providing these constitutionally protected rights.
PublicSource is identifying Chester, 36, only by his first name. He has schizoaffective disorder — an illness that causes hallucinations and affects his mood and behavior, including the incident that spurred a provider to involve the court in his treatment.
Chester was “wandering around at night,” tracing “a path” along the graffiti under local bridges. He thought they were messages addressed to him, he said from his single-room occupancy unit in a Hudson Valley town. Tormented by these bouts of psychosis, he grabbed a bucket of turpentine to wipe away the graffiti. With the bucket in hand, he told a staffer at the shelter he was staying in that he “should have burned down all the bridges instead of asking for help.”
“I was just upset with everyone,” he said, referring to the clinical team treating him. They promised to help him file a workers’ compensation claim for a brutal beating he’d suffered while working a security job in 2020. But no one followed through, he said, and he never got the benefits he needed for physical therapy.
Chester doesn’t think his actions warranted an AOT order — he wasn’t literally going to burn bridges, he said. He felt his attorney didn’t advocate for him by explaining that context. He’d also gone six months without medication at one point because his doctor wouldn’t prescribe oral tablets, which he prefers over long-acting injectables. He was considered to have a history of non-adherence to treatment. The judge granted the order, which has been renewed twice so far.
“I wasn’t satisfied” with my legal representation, he said. “The lawyer doesn’t have enough time.”
What’s required for a robust due process?
County human services Director Erin Dalton told a state official in December that Allegheny County would implement AOT by Sept. 1. During an interview in May, she clarified that the county hasn’t yet made the decision to do so. She and her team are weighing how to balance civil liberties with getting care to people in crisis, pointing to AOT as a possible way to prevent poor outcomes after they’re released from involuntarily hospitalization.
The department has been regularly convening a group of stakeholders from across county government to discuss how AOT could be implemented effectively in Allegheny County. In response to questions about due process, a Department of Human Services spokesperson said the agency believes in “strong legal protections” and “won’t shy away from tough conversations to make sure people are well-represented.”
A disability rights attorney with lived experience of involuntary treatment described why due process is so important during AOT court proceedings.
“What we’re looking at is a process that allows someone to be hauled into court and then a judge to decide what treatment they’re going to receive based on a prediction that they may or may not experience harm in the future,” said Brynne Madway, a staff attorney for Disability Rights Pennsylvania, which provides legal aid to people with disabilities in the state.
She listed what people facing involuntary treatment should have at a minimum:
A “well-prepared” attorney who has time to meet with a client before their hearing
The opportunity to consult with independent experts, such as a psychiatrist, psychologist or other mental health professional
A judge or mental health review officer “who is impartial and will rule on the evidence.”
“But anecdotally, I’ve heard of these things being scheduled very quickly, or where the attorneys don’t have the opportunity, even if there’s notice, to consult with their clients far in advance of the hearing,” said Madway, who’s spoken with court-appointed attorneys in New York, Oregon and other states.
“I think the public defender’s offices do absolutely fantastic work for their clients, day in and day out, but attorneys only have so many hours in a day, and there’s a point at which you cannot increase caseloads without decreasing the quality of representation.”
Public defenders roll up their sleeves
If the county implements AOT, attorneys from the county’s Office of the Public Defender will represent people who become the subject of a petition.
They’ll zealously advocate for those clients, said Sarah Linder Marx, the senior deputy director of public outreach and staff development. That means arguing the client’s position — such as their desire to fight an AOT petition — even if the attorney feels it’s not in their best interest.
But they expect an AOT program will further strain the office’s overburdened staff of about 100 attorneys, only five of whom specialize in mental health commitment hearings. The office hopes to beef up that unit, but Linder Marx said it doesn’t have the resources to hire the number of attorneys it needs to make AOT less “burdensome.”
If we’re going to be on call or we’re going to have to do shift work, that will likely be what we do. – Sarah Linder Marx, the senior deputy director of public outreach and staff development for the Allegheny County Office of the Public Defender
Samantha Sridaran, the attorney who leads that unit, described the two types of AOT the office will have to handle: “step-down” for those leaving inpatient commitment and “step-up” for those in the community. She met with her counterparts at the Los Angeles County Public Defender’s Office to learn how they build trust with the step-up population, which is the hardest to reach.
“These aren’t clients who are going to come into the office, especially when you’re like, ‘Well, you’ve got a possibility of an involuntary commitment,’” Sridaran said. “You have to physically meet with them right where they’re at in the community and try to talk with them,” she said, explaining that LA’s office has a dedicated attorney and social worker who do this work.
Sridaran brought the idea to the county’s Department of Human Services. “But I have not heard anything back from that.”
With no guarantee of additional resources for AOT, attorneys across the office’s divisions are preparing to lighten the load for Sridaran’s unit. Linder Marx said they’re training up and “sharpening [their] legal analysis” of the state’s Mental Health Procedures Act. (It was amended by state lawmakers in 2018 to make AOT possible in Pennsylvania.) Even leadership is training to cover hearings if they have to, she said.
“If we’re going to be on call or we’re going to have to do shift work, that will likely be what we do, until we can at least ask for more resources,” she said.
Asked if the county will provide those resources, Director of Communications Abigail Gardner noted the public defender’s office’s funding jumped from about $11.8 million in 2023 to $14.8 million this year. “Recognizing that the public defender’s office has historically been underfunded and overworked, the county executive has made it a priority to invest in [it] and will continue to do so regardless of if AOT is implemented or not,” she wrote.
Linder Marx said the office has received more help from the Innamorato administration “in the budget than we’ve ever gotten from anyone.” But there would be “a resource battle” among its divisions if AOT is implemented without a grant or funding specifically earmarked to cover the cost of representing those clients.
The black robe effect
Legal experts said Pennsylvania’s AOT statute is toothless. It bars courts from holding a person in contempt for not following their treatment plan, though the court can order an evaluation for a step-up in the form of inpatient commitment.
Unable to impose penalties, all the court can do is intimidate the person under AOT into adhering with their treatment plan, said Madway, the disability rights attorney.
It’s “not a great law,” Dalton told PublicSource in May. “And yet, it might still help people to adhere to care post hospitalization.” Proponents of AOT call it “the black robe effect,” or the idea that a judicial process will increase a patient’s likelihood to stick to their treatment plan.
But some experts are skeptical of the theory, noting that AOT is based on the idea that people with serious mental illness lack insight into their need for treatment and services.
“A piece of paper” explaining the consequences if they don’t adhere to treatment in the community is unlikely to “magically” give them insight, said Jennifer Mathis, deputy director of the Judge David L. Bazelon Center for Mental Health Law, a Washington, D.C.-based group that advocates for the civil rights of people with mental disabilities.
Another disability rights attorney said the lack of specific enforcement provisions “can almost make things worse” because it makes it difficult to challenge AOT laws.
“The New York Courts said, ‘Well, it’s fine because if a person doesn’t comply, there’s nothing bad that can happen to the person or they might just be sent for an emergency evaluation,’” said Courtney Bergan, the equal justice works fellow at Disability Rights Maryland. “It ignores how traumatizing this can be for individuals who are subject to it,” which “can lead to longer-term disengagement from the system.”
AOT — a civil procedure — can influence criminal legal outcomes in New York, according to a court-appointed attorney there.
“Sometimes I feel like the system can say, ‘Well, I’ll give this person a lesser charge if they’ll go on AOT,’” said Katherine Bajuk, a senior trial attorney and mental health specialist at New York County Defender Services, who represents people facing criminal charges in Manhattan. “There is a coercive element to that,” she added.
Linder Marx said she “would not be surprised” if that “became the reality” here, describing similar negotiations in domestic violence cases in the county, in which a person must either agree to be placed under a protection from abuse order or fight an indirect criminal contempt charge.
In the case of AOT, “it will be coercive” to a vulnerable population. “We’re not jazzed up about it.” But “if a person is [already under an AOT order] … I would definitely want to use that to better their legal position [in a criminal case], and I do think there would be situations in which that was attractive to the district attorney’s office.”
Those negotiations are “fraught with ethical implications,” said Madway, the disability rights attorney. “You would potentially be asking someone to choose what type of liberty to sacrifice,” she said.
Though people with mental illness are disproportionately criminalized, research shows they’re more likely to be the victim of a violent crime than the perpetrator.
How should the court protect due process?
In May, PublicSource asked the Court of Common Pleas detailed questions about its role in AOT implementation, how it would proceed if a person doesn’t adhere to treatment and how it would minimize harm and safeguard civil liberties.
Spokesperson Joseph Asturi didn’t answer those questions, but wrote the court “is pleased” the county is considering AOT, which would give judges, families and clinicians “more options to help people experiencing a mental health crisis.”
Experts and advocates described what courts should do to protect due process.
Courts should document the nature, intensity and result of any services that were provided to a person who is the subject of an AOT petition, said Mathis, a former deputy assistant attorney general in the U.S. Justice Department’s Civil Rights Division.
That documentation should show that “adequate voluntary services cannot help a person survive in the community and [AOT] is truly an alternative to inpatient hospitalization that otherwise would be imposed,” she added.
Bergan encouraged the community to “keep their eyes open and be willing to see that this is not a panacea.
“People refuse treatment for a reason,” she said. “It’s usually not, ‘I don’t believe I need treatment,’ but ‘I’m experiencing side effects.’ And listen to that and offer alternatives, [which is] what’s really going to solve the problems that people want to solve with AOT.”
In upstate New York, Chester is resigned to the annual court process that determines if his AOT order should be renewed. He was represented by a different attorney during each of the three court hearings about the order, and said he didn’t have enough time to work with any of them.
Asked how he’d like his legal representation and due process rights to improve, he said, “I actually don’t care at this point.”
Venuri Siriwardane is PublicSource’s health and mental health reporter. She can be reached at [email protected] or on Bluesky @venuri.bsky.social.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s health care reporting.
This story was fact-checked by Ayla Saeed.
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