Wait for the crisis. Then respond. For decades, that has been the operating principle of mental health care in America — not because anyone chose it deliberately, but because it became the default. Dr. Andy Keller of the Meadows Mental Health Policy Institute has spent his career trying to change that.
"Our mission, our goal is to basically help treatment for mental illnesses like these to be at least as good as treatment for cancer or heart disease." — Dr. Andy Keller
The comparison to heart disease is not rhetorical. It is clinical.
"It used to be that when you had heart disease, we didn't treat you until your heart stopped. That was when my grandpa got diagnosed with his heart disease — when they woke him up after resuscitating him from being dead." — Dr. Andy Keller
That was the standard of care. Wait for the crisis. Today, Dr. Keller says, mental illness is still treated the same way.
"That's a lot how we do it right now with mental illness. Like we don't go out there until there's a crisis." — Dr. Andy Keller
The Cost of Waiting
Judge Steve Leifman has spent thirty years on the bench in Miami-Dade County. He has watched the consequences of that delay accumulate — in courtrooms, in jails, on sidewalks. He does not mince words.
"We wouldn't treat people with cancer or heart disease the way we treat people with mental illnesses. If someone has a heart attack on the side of the street, we're going to call 911. They'll be taken to a hospital. If they need emergency surgery, they're going to get involuntary treatment against their will — no one's asked. But then they're going to have a really good shot at having a full and happy life. And insurance is most likely going to cover their cost. But God forbid you have a heart attack of the brain where you have a psychotic disorder. We're kind of scared of you. We're going to let you hang out on the street and watch your brain deficits increase by allowing your gray matter to get destroyed over a decade." — Judge Steve Leifman
A heart attack of the brain. For Dr. Keller, that is the clinical reality of a psychotic break — and the window for intervention closes slowly, then all at once.
"On average, it's five years later when we get care to people for these particular illnesses — two to five, depending on what studies you look at." — Dr. Andy Keller
Five years. In those five years, a person's illness advances. Their family exhausts itself. The criminal justice system accumulates the cost.
"The way we do it now is expensive. It doesn't work. It makes things worse — and it frustrates the heck out of everybody."— Judge Steve Leifman
The numbers behind that frustration are staggering.
"Today in the United States, 70% of people who are in jail either have a serious mental illness, a substance use disorder, or both." — Judge Steve Leifman
Judge Leifman has arrived at what he considers the only logical conclusion.
"I say it like a joke but maybe we need specialty courts for the 30% of people that don't have these disorders. And we need a therapeutic jurisprudence system for the 70% that do — because just having small mental health courts that handle very few people does very little to curb the problem." — Judge Steve Leifman
The Brain Is an Organ
Judge Oscar Kazen of San Antonio has been making this argument at conference room tables in Bexar County for more than twenty years. The argument is simple. It has proven surprisingly hard to land.
"Just getting people to understand that having a mental health issue doesn't make you less than anybody else. It's if they had a heart condition. And I reached over and took the medication away from them — they would fight me to the death to have their heart medication back. But change that heart medication to mental health medication or psychotropics. And it's the other way around. They won't even acknowledge that they're ill. The mind is just another organ. It has its issues." — Judge Oscar Kazen
The Moral Case
Eric Smith has thought about this more deeply than most — because he has lived inside the answer. He draws a comparison that cuts through the policy debate entirely.
"When Alzheimer's and dementia hits — which is qualitatively different from psychosis as I lived it — but the Venn diagram here, the overlap, is I could not perceive reality due to psychosis. Alzheimer's and dementia also prevents people from perceiving reality. But as a society, what do we say to Alzheimer's and dementia? We say, yeah, let's bring in the family. Let's make sure we don't leave the loved one alone in the kitchen. But everyone's brought in as a team approach. All working together for the benefit of the person suffering." — Eric Smith
Smith was in his twenties when he was suffering. The system looked at him and saw a young man exercising a right — rather than a patient experiencing a symptom.
"But why? Because when I couldn't perceive reality, I was in my 20s. And so society, up until AOT, was essentially like, yeah, but as a young man, he doesn't want treatment. Leave him alone." — Eric Smith
He does not accept that framing. He has not accepted it since.
"Would you say that to an elderly person who could not perceive reality? And if someone comes back and says, yeah, I also believe that we should leave people with Alzheimer's and dementia alone, I'll be like, I appreciate your consistency — but that is insane. We have to be able to help people who cannot help themselves. It is the strongest measure of society." — Eric Smith
"No one's doing me or anyone else any favors to let us die on the street, psychotic — saying, well, they said they didn't want treatment. We respected that. Their choice." — Eric Smith
What Happens When It Works
When the system chooses to treat a brain the way it treats a heart — what happens? Judge Kazen has watched it happen, case by case, across two decades.
"Make wellness their habit. And once you do, amazing things happen." — Judge Oscar Kazen
One week becomes a month. A month becomes a year. For Eric Smith, it became a life.
"I couldn't have gotten to all of these fun, shiny, happier, pretty parts of my life without all of the chaos before it. And there is truly not a chance that I would have made it to where I'm at right now — happy, healthy, living a life of purpose and meaning — without a huge team of people helping navigate through the chaos." — Eric Smith
Start Screaming
Eric Smith carries that message forward — on behalf of every person whose story closely parallels his and who has chosen silence because the stigma still makes exposure dangerous.
"There are a lot of Eric Smiths out there. Many of them are people I've met through the work that I do. It's just through necessity — professional and personal and academic necessity — they feel the need to just kind of be more quiet about it. I can't wait till we live in a time where people feel like they can share all of it as freely as we share diabetes, broken leg, high cholesterol, blood pressure issues. It's just some other medical issue that is worthy of a more elegant solution." — Eric Smith
The elegant solution exists. It has been demonstrated in Miami. It has been built in San Antonio. It has been legislated in Austin. The models are not theoretical. They are operational, documented, and proven over decades of data.
What remains is will.
"If you have any kind of soul at all — use what you have to help people." — Judge Oscar Kazen
"What I believe needs to be truly screamed from the top of our lungs is that sometimes it is appropriate to engage with coercive care. No one's doing me or anyone else any favors to let us die on the street, psychotic — saying they didn't want treatment. We respected that. That is truly resulting in deaths and preventable tragedies." — Eric Smith
There are a lot of Eric Smiths. They are in your city. They are in rural West Texas, where the distance to help is measured in hours. They are in your family. You may not know it yet.
"It is a human soul we're trying to save. How do we work together to get there?" — Judge Oscar Kazen
The distance between a person in crisis and the help they need is no longer a matter of what is possible. It is a matter of will.