The Maine State House seen at sunrise in January. Anna Chadwick/Morning Sentinel

The Army reservist had been acting paranoid for months. He had threatened a fellow soldier and admitted to having a “hit list.” But even though they diagnosed the reservist with psychosis, doctors at a New York hospital allowed him to leave after a two week stay. Less than three months later, he committed the deadliest mass shooting in Maine’s history.

As we approach the one-year anniversary, many details about the gunman’s medical treatment remain elusive. His medical records remain sealed. Doctors and hospital staff who were involved in his care have refused to discuss the case.

The Portland Press Herald, in partnership with Maine Public and FRONTLINE, spent months talking to experts about our mental health system, including what options are available to treat people who refuse help. Our investigation led us to the Progressive Treatment Plan (PTP), a law that can compel those with serious mental illnesses to adhere to outpatient treatment plans while still living in their own communities but is rarely used in practice.

Here are four key findings.

IT’S SELDOM USED

Like nearly every other state in the nation, Maine has an assisted outpatient treatment law, which is meant to be a less intrusive alternative to traditional inpatient psychiatric commitment. But it’s rarely used.

Proponents of the progressive treatment program believe it could have pushed the Lewiston gunman to accept help before he became violent. Yet many law enforcement officials, including the officer who responded to warnings about the reservist’s failing mental health last September, don’t even know it exists.

So, what is PTP? Maine’s program requires patients with mental illness to comply with treatment outside of a hospital. To place someone on a PTP, a clinician, law enforcement official or the patient’s guardian must prove several facts: that the patient suffers from “severe and persistent mental illness,” that they pose a likelihood of serious harm, and that they are unlikely to follow a treatment plan voluntarily.

If a court agrees, an intensive case manager or a group home monitors the patient to ensure they are complying with the plan. If they aren’t, the patient can be committed in an inpatient setting until they return to compliance.

The state doesn’t regularly track the total number of PTP orders, but as of Oct. 4, there were 78 people on PTPs that had been initiated by the two state-run psychiatric hospitals.

IT’S NOT WIDELY ACCEPTED

These programs aren’t universally accepted, however. Patient rights advocates say the argument that patients with mental illnesses don’t know what’s best for them is paternalistic.

Many in the patient advocacy world believe involuntary care, even in an outpatient setting, is wrong for several reasons: treating someone who doesn’t want to be treated isn’t effective; it’s dehumanizing; and it takes attention away from real steps that could improve the mental health system.

And these skeptics say there’s little evidence that involuntary treatment programs improve public safety.

LAW ENFORCEMENT ISN’T WIDELY TRAINED

The law has been on the books for well over a decade and while it’s a “program” under state law, it’s not one that Maine’s Department of Health and Human Services says it’s responsible for implementing. And from what we can tell, no one is willing to take responsibility for training law enforcement how to use it.

When we asked law enforcement leaders in Maine what they knew about it, most had little to no knowledge of the PTP law and thought a reporter was referring to the state’s involuntary inpatient commitment process (where someone is held at a state or private facility), usually called “blue papering.” And those who do know about it, don’t know enough to actually put it to use.

Sanford’s deputy police chief Matthew Gagné said his department’s dedicated mental health team is aware of the program but rarely, if ever, initiates PTP petitions.

Maine Police Academy cadets go through more than 20 hours of training on mental health and behavioral training, but that does not include specific instruction on PTP – and that’s because the academy views them as “more appropriately handled by clinicians and other specialists who are better positioned to manage these responsibilities.”

Even though the statute technically says police can initiate the PTP process, several people who spoke with the Press Herald said that, in practice, it is only ever initiated by medical providers when an already hospitalized patient is being discharged.

POTENTIAL IMPROVEMENTS TO THE LAW HAVEN’T BEEN FUNDED

And while Maine legislators have consistently supported the PTP statute in theory, they’ve never adequately funded programs that would make it easier to use.

A 2022 bill that would have assigned someone within DHHS to train police and medical providers to use the law and determine what data should be collected in the future died on the appropriations table after officials estimated the measure would cost just over $272,000.