Involuntary Outpatient Commitment

The “Helping Families in Mental Health Crisis Act” would mean a step backwards for securing broad access to care and other protections for persons with psychiatric disabilities. The bill prioritizes and advocates for the expansion of “assisted outpatient treatment” (AOT), a euphemistic term used to describe involuntary outpatient commitment ordered by a court, with the threat of involuntary inpatient hospitalization for those who do not comply with their treatment orders.

An expansion of court-ordered treatment is problematic for the following reasons:

There is no evidence that using a court order to mandate outpatient treatment is effective.

  • Repeated studies have shown no evidence that mandating outpatient treatment through a court order is effective; to the limited extent that court-ordered outpatient treatment has shown improved outcomes, these outcomes appear to result from the intensive services that have been made available to participants rather than from the existence of a court order mandating treatment.[1]
  • Two systematic reviews have been done of studies concerning involuntary outpatient commitment in the United States. Both reached the same conclusion: there is no evidence that mandating outpatient treatment is more effective than providing such treatment on a voluntary basis.[2] RAND Health found that there was clear evidence that “alternative community-based mental health treatments can produce good outcomes for people with severe mental illness.”[3]
  • 2010 study of New York’s outpatient commitment program found that patients in the outpatient group acknowledged that “assisted outpatient treatment clients also received other enhanced services, such as priority for housing and vocational services. We cannot conclude which of these elements of the package deal contributed most to the generally positive outcomes for participants. We therefore caution against using our results to justify an expansion of coercion in psychiatric treatment.”
  • 2001 study of outpatient commitment in North Carolina found that the outpatient commitment group reported greater feelings of perceived coercion, which often leads to self-reported low medication adherencehigher feelings of devaluation and discrimination, and lower quality of life in discharged patients. The North Carolina study ultimately recommended against the expansion of coercive treatment, concluding: “A court order alone cannot substitute for effective treatment in improving outcomes.” Indeed, these legislative measures may be preventing people with mental illness from seeking help.
  • Common sense, cost concerns, and concerns about forced treatment undermining patient-provider relationships and driving individuals away from treatment dictate that we engage people and offer voluntary treatment before restricting their freedom with coercive interventions.[4]
  • 2003 survey of people diagnosed with schizophrenia indicated that 36% of people resisted seeking help for fear of coerced treatment.
  • The Well Being Project, a research project supported by the California Department of Mental Health, found that 55% of clients interviewed who had experienced forced treatment reported that fear of forced treatment caused them to avoid all treatment for psychological and emotional problems.

We should be focusing on expanding a range of voluntary services, not forcing people into broken systems.

  • Court-ordered treatment can be averted when adequate mental health services and interventions are in place to provide the necessary support at the early stages of mental illness.[5]
  • Such successful, evidence based interventions include mobile crisis teams, intensive case management, and supported housing.[6]
  • Mental health experts believe that access to comprehensive, community-based voluntary mental health treatment and services offer the best chances of recovery. As one expert noted, “On balance, after more than 20 years of mandates and programs, outpatient commitment remains a costly, coercive, and unproven approach. More promising, and proven, practices are available.”[7]

There is no evidence that mandatory outpatient treatment improves public safety.

  • People who are a danger to themselves or others due to their mental disability may, under current law, be hospitalized and held against their will. But, when safety is not threatened, voluntary treatment is the best approach, not only because it provides the greatest protection of and respect for an individual, but also because it typically often yields long term engagement in treatment.[8]
  • Expanding services that avoid mental health crises in the first place—and that are in short supply in all states—would better serve our communities.
  • People with psychiatric disabilities are no more prone to violence than the general population.[9] Further, violent behaviors in everyone are more common when other risk factors are also present, including abuse, drug or alcohol dependence, and recent stressors such as being a crime victim or losing a job.[10] Thus, if public safety is the goal, our focus should be on ensuring that effective, voluntary treatment, is widely available to everyone.

Involuntary outpatient commitment is often disproportionately applied to minorities.
According to a 2014 report, “Studies on outpatient civil commitment conducted in North Carolina and New York revealed that people of color and those living in poverty are disproportionately impacted by involuntary community treatment orders.”

  • In North Carolina, two-thirds of individuals court-ordered to community treatment were African American, despite only representing approximately 22% of the total state population.
  • In New York, African Americans were subjected to court orders five times more frequently than whites, while Latinos were two and a half times more likely than whites to be under a court order.
  • The pervasive institutional racism in the mental health system must be addressed. African Americans are overrepresented in coercive interventions and underrepresented in voluntary, community-based care.

According to a 2014 report, “A court order is simply not necessary to create a well-designed program to engage people in treatment and significantly improve outcomes for the at-risk population. Moreover, a voluntary program avoids the significant problems attendant to outpatient civil commitment – discrimination and deprivation of civil liberties, racial/economic/geographic disparities, and unnecessary legal, court and enforcement costs.”

[1] See Dr. Michael Rowe, Alternatives to Outpatient Commitment, 41 J. Amer. Acad. of Psychiatry and the Law 332 (Sept. 1, 2013), http://www.jaapl.org/content/41/3/332.full.pdf+html (describing the studies).

[2] M. Susan Ridgely, Randy Borum and John Petrila, RAND Health, The Effectiveness of Involuntary Outpatient Treatment (2001), http://www.rand.org/content/dam/rand/pubs/monograph_reports/2007/MR1340.pdf; Steve R. Kisely, Leslie Anne Campbell, and Neil J. Preston, Compulsory community and involuntary outpatient treatment for people with severe mental disorders, Cochrane Database of Systematic Reviews (Feb. 2012).

[3] Ridgely et al., supra note 2.

[4] No Good Evidence for Outpatient Commitment, Courant (Feb. 5, 2014), http://www.courant.com/news/opinion/letters/hcrs-18599–20140204,0,1263487.story.

[5] Outpatient and Civil Commitment, Judge David L. Bazelon Center for Mental Health Law, https://www.bazelon.org/Where-We-Stand/Self-Determination/Forced-Treatment/Outpatient-and-Civil-Commitment.aspx.

[6] Id.

[7] See Dr. Michael Rowe, supra note 1, at 335-36.

[8] See id. at 333 (noting comments of clinician that “when informed of their potential eligibility for outpatient commitment, almost all [of his male clients residing in a shelter] fled the shelter and were not seen again.”).

[9] Jerry Zremski, Better Care For Mentally Ill Won’t be Enough, Experts Say, Buffalo News (Dec. 16, 2012), http://www.buffalonews.com/apps/pbcs.dll/article?AID=/20121215/CITYANDREGION/121219410/1010; Eric B. Elbogen & Sally C. Johnson, The Intricate Link Between Violence and Mental Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions, 66 Arch. Gen. Psychiatry 152, 157 (Feb. 2009); Henry J. Steadman, et al., Violence by People Discharged from Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods, 55 Arch. Gen. Psychiatry 393, 400 (May 1998).

[10] Eric Elbogen and Sally C. Johnson, Mental Illness by Itself Does Not Predict Future Violent Behavior, Study Finds, Science Daily (Feb. 3, 2009), http://www.sciencedaily.com/releases/2009/02/090202174814.htm.