Coercion is the power to force compliance with authority using threats of physical punishment, deprivation and/or other undesirable consequences (Geller et. al, 2006). The fact of government coercion is inescapable, as it is the basis of an effective social control model. However, state intervention into the lives of its citizens is not equally distributed across the population. A major point of contention surrounds the ethics and efficacy of using involuntary outpatient commitment to mandate the treatment of mental illness. This post reviews the academic literature to present competing perspectives on this hotly debated topic.

What Is Involuntary Outpatient Commitment?

Involuntary outpatient commitment is a legal mechanism that mandates treatment for individuals with mental illness. As a condition of living in the community, people with psychiatric disorders must comply with court-ordered psychotropic drug and treatment demands. Compulsory measures often include that “a person participate in full-day treatment programs, undergo urine and blood tests, frequently attend meetings of addiction self-help groups, enter psychotherapy with a particular therapist, or reside in a supervised living situation” (Allen & Smith, 2001:342). An additional mechanism entails that a representative (also known as a ‘rep-payee’) control the budget of the person with mental illness. All of this is based on the premise that mental illness, when untreated, will become worse and adversely impact self and/or others.

Types of Involuntary Outpatient Commitment

There are three types of involuntary outpatient commitment:

  • Conditional release: Individuals are discharged from an inpatient setting into society. After an improvement of symptoms at the hospital, the person with mental illness is granted the privilege of living in the community. Continuation of this arrangement is contingent upon adherence to a treatment plan that often involves consumption of psychotropic medication (McCaffetery & Dooley, 1990).
  • Assisted outpatient treatment: This type of outpatient commitment uses the same standard as inpatient commitment, but gives individuals with mental illness the opportunity to live in the community (Geller et. al 2006). In comparison to inpatient treatment, this is deemed less restrictive.
  • Preventive outpatient commitment: Unlike assisted outpatient commitment, preventive outpatient commitment does not require a person meet inpatient standards (Cornwell & Deeney, 2003). Thus, persons with mental illness are coerced into outpatient treatment before they become a danger to self or others. At present, 42 states and the District of Columbia have involuntary commitment laws; with preventive outpatient commitment being legal in nine. In many areas, the time-frame for which treatment is compelled is both vague and expanded without uniformity (Bazelon Center, 1999).

Legal Doctrine & the Power of the State

There are two legal principles that grant the United States government the capacity to compel individuals with mental illness: police power, and parens patriae. These two doctrines have traditionally been applied to justify the interference of government in matters of personal autonomy. First, the state’s police power refers to the ability to prevent harm within the community. In mental health settings, “this justification is utilized when the behavior of a person with mental illness causes them to become a risk or harm to others” (Geller et. al 2006: 552). Ensuring public safety from the potential violence of individuals with mental illness is the main objective. The fulcrum of this legal standard is the idea of dangerousness. In Addington v Texas, the Supreme Court declared that the state has the power “to protect the community from the dangerous tendencies of those who are mentally ill” (emphasis added, 1979: 1). To accomplish this goal, clinical assessments are made about present danger or the likelihood of future harm. More concretely, the police power of the state compels a person with mental illness to submit to treatment because of existing or predicted violence.

The second justification for state intervention into the lives of people with mental illness is parens patriae. A clue into the nature of this principle is the Latin translation of the term, which is ‘parent of the fatherland.’ This legal standard is applied by the state to infringe upon the right to autonomy when the person’s “ability to make autonomous decisions is impaired to the extent that they become a risk to themselves” (Geller et. al 2006: 552). The state’s application of this justification often centers on the notion of competence. While individuals with mental illness are free to refuse treatment, the question is: does the person know they have the illness? In the event that the mentally ill person is unable to acknowledge their illness, the state can act in the ‘best interest’ of the individual by coercing them into treatment.

Are the Mentally Ill More Violent? 

A common justification used to support involuntary outpatient commitment is preventing harm to others. Kress (2000) contends that the violence perpetrated by people with mental illness often occurs when they are not being treated. The impulse here is that the physical harm inflicted by individuals with mental illness can be diverted with involuntary outpatient commitment. Interestingly, many preventive outpatient commitment laws have their root in highly publicized crimes committed by people with mental illness. For instance, ‘Kendra’s Law’ and ‘Laura’s Law’ were implemented in New York and North Carolina, respectively, as responses to murders committed by men with untreated delusions. While it is true that people with mental illness are no more likely to commit violence than the general population (Mental Health America, 2014), Torrey (1998) postulates that a subset of individuals with severe mental illness are more dangerous. The high resistance to treatment amongst this group exposes masses of people to tragedies that could have been prevented.

Research has evaluated the relationship between violence and mental illness. Overall, violence amongst persons with mental illness is indeed concentrated to a very small sub-population of the group. Link (1992) found that three symptoms of psychosis were related to violent behavior: the belief that other people wished to do harm to you, that your mind was dominated by forces beyond your control, and that existing thoughts were not your own. These symptoms have been termed threat/control-override. After controlling for sociodemographic factors (i.e. age, gender, etc) these symptoms were not appreciably higher than other social determinants as indicators of violence. Additionally, a study conducted by Stuart & Florez (2001) found that violence was higher among individuals struggling with substance abuse. In the final analysis, people with mental illness are more likely to be victims of violence than perpetrators (Mental Health America, 2014).

Double Maneuver of the State

One of the goals of involuntary outpatient treatment is to ensure public safety. However, Allen & Smith (2001) challenge the conventional belief that outpatient treatment is more advantageous than voluntary treatment in accomplishing this objective. They argue “when compared head-to-head with a program of enhanced and coordinated services, outpatient commitment is no more effective in preventing subsequent acts of violence and arrest” (p. 343). Hence, the usage of coercion to involuntarily commit people with mental illness to treatment may be unwarranted. The unchallenged link between ‘danger to others’ and the need for involuntary outpatient commitment misses two facts: 1). most people are willing to participate in treatment, and 2). there is a lack of resources that prevents people from receiving care. According to Mental Health America (2014), the mental health system has suffered $4.6 billion in budget cuts since 2009, and lacks the capacity to meet current demands. Discourse regarding a danger to others elides the fact that access to treatment is increasingly difficult. The state performs a double maneuver in this regard: it destabilizes the mental health system by withdrawing economically, only to re-insert itself as the provider of protection from the very group it continues to destabilize. Thus, it may be important to question widespread definitions of safety.

Violence Cannot Be Predicted

A premise supporting preventive outpatient treatment is that violence can be predicted. However, research has shown that risk assessments yield results that are similar to chance. Lidz et. al (1993) found that psychiatrists successfully identified 58% of individuals who did not engage in violence and 60% of people who did. These results are not impressive enough to justify preventive treatment. Mental Health America (2014) contends “mental health professionals possess no special knowledge or ability to predict future dangerous behavior” (p. 1). Nonetheless, there are at least four competing ways to frame the effectiveness or ineffectiveness of risk assessments. First, while the aforementioned results are not significantly better than chance, they are the best the system of mental health can offer. This imperfect system will help decrease the number of preventable attacks by screening for dangerous tendencies. Second, since violence assessments will inevitably yield false positives, individuals who truly pose no risk to public safety will be forced to forfeit their autonomy. The problem here is that people will lose their liberty and be unfairly criminalized in a way that does not improve their condition. Third, violence is a complex phenomena, and what ‘counts’ as violence is rooted in political, economic, and social structures. Thus, an individual level of analysis elides the social structures that work in tandem in producing this behavior. Fourth, the wisdom of a risk assessment is ill-advised. The social world changes constantly. However, violence assessments are based on an isolated snapshot of a ever-fluctuating terrain. It is thus impossible to make accurate predictions of violence.

The Failures of Parens Patriae

A subset of the parens patriae principle is the idea that people with severe mental illnesses have impaired insight. The argument from this perspective is that the severity of certain psychiatric disorders leads to anosognosia: lacking awareness of one’s illness. Torrey & Zdanowicz (2001) posit that schizophrenia and bipolar disorder damage the brain and negatively affect decision-making capacities. These neurologically-based incapacitations render people incapable of making informed medical decisions regarding treatment. While this line of reasoning is persuasive on a visceral level, basic research on these claims reveals unconvincing results. Flashman et. al(2000) analyzed physical abnormalities of the brain and the presence of absence of ‘insight,’ and found no definitive evidence.

A fatal flaw with the application of parens patriae is that most states do not require a determination of incompetence. This is asinine – especially when the fact that most people with mental illness are competent is considered (Appelbaum, 1994). This is more than mere paternalism; it is the state’s attempt to present itself as the all-knowing, all-seeing, all-wise Supreme Being. While a doctrine of American jurisprudence is ‘innocent until proven guilty’ – the courts in many states invert this logic. This hostile perspective does more to exacerbate mental illness than improve it. In an attempt to recalibrate this, the first right elucidated on the website of Mental Health America (2014) is:

                Presumption of Competence: It is a basic principle of American law that all adults are presumed to be “competent” – that is, they are presumed to be capable of making their own decisions about their own lives and their own medical care,  including mental health treatment.

An additional problem with state intervention on the grounds that an individual poses a harm to self is that it reinforces the mind/body schism. The theory and application of parens patriae is the idea that mental illness and physical illness are different. Most notably, mental illness is tethered to a discourse on danger that compels state intervention. People with mental illness are said to be a ‘danger to self’ when they refuse treatment. However, a person who smokes cigarettes and refuses treatment is not said to be a ‘danger to self,’ even though nicotine is clearly a problem for their health. Thus, state intervention is not equally distributed across the population.

By way of conclusion, there are advantages and disadvantages to involuntary outpatient commitment. A benefit of involuntary outpatient commitment is that people with mental illness who otherwise would not consent to treatment are helped while they are – or before they can – become a danger to self or others. However, a disadvantage is that there is little evidence that court-ordered treatment yields better results than community-based approaches. As Wales & Hiday (2006) argue, an alternative to the persuasion, leverage, and coercion exercised by the state is the tender love and care of patient-centered treatment.

 

References/Further Reading: 

Addington v Texas 441 U.S. 418 (1979)

Ahmedani, Brian et al.,2012. Suicide Thoughts and Attempts and Psychiatric Treatment        Utilization: Informing Prevention Strategies. Psychiatric Services, 63 (186): 124-129

Allen, Michael & Vicki Smith. 2001. Opening Pandora’s Box: The Practical and Legal   Dangers of Involuntary Outpatient Commitment. Psychiatric Services, 52 (3): 342- 346

Appelbaum, Paul. 1994. Almost a Revolution: Mental Health Law and the Limits of Change,   Journal of Psychiatry 129: 18-22

Bazelon Center for Mental Health Law, Summary of Statutes on Involuntary Outpatient             Commitment (1999). Available at http://www.bazelon.org/iocchart.html

Burns, Tom. Jorun Rugkasa et. al. 2013. Community Treatment Orders for Patients with        Psychosis. The Lancet, 381 (9878) 1627-1733

Cornwell, John & Raymond Deeney, Exposing the Myths Surrounding Outpatient        Commitment for Individuals with Chronic Mental Illness, Psychology and Public   Policy 209: 135-179

Flashman, Laura et al. 2000. Brain Size Associated with Unawareness of Illness in Patients   with Schizophrenia. American Journal of Psychiatry, 157 (7) 1167-1169

Geller, Jeffrey., William Fisher., Albert Grudzinskas., Jonathan Clayfield., Ted Lawlor. 2006. Involuntary Outpatient Treatment as ‘Deinstitutionalized Coercion’: The Net- Widening Concerns. International Journal of Law and Psychiatry, 29:551-562

Grob, Gerald. 1994. The Mad Among Us: The History of the Care of America’s Mentally Ill.     Free Press: NY

Kress, Ken. 2000. An Argument for Assisted Outpatient Treatment for People with Serious   Mental Illness Illustrated with Reference to a Proposed Statute for Iowa. Iowa Law     Review. 85 1269-1283

Lidz, Charles et al. 1993. The Accuracy of Predictions of Violence to Others, Journal of            American Medical Association, (269) 1007

Link, Bruce et al. 1992. The Violent and Illegal Behavior of Mental Patients Reconsidered.     American Sociological Review, 13: 275-278

Markowitz, Fred. 2011. Mental Illness, Crime and Violence: Risk, Context and Social Control.             Aggression and Violent Behavior, 16: 36-38

McCafferty, Gerry & Jeanne Dooley. 1990. Involuntary Outpatient Commitment. Mental         Health and Physical Disability Law Report, 14 (3):277-287

Mental Health America, 2014. Available at: http://www.nmha.org/positions/involuntary-    treatment

Olfson, Mark. 2000. Predicting Medication Noncompliance After Hospital Discharge Among Patients with Schizophrenia, Psychiatric Services, 52 (264): 216-220

Ridgely, M.S.; Borum, Randy; and Petrila, John. 2001. “The effectiveness of involuntary          outpatient treatment: Empirical evidence and the experience of eight states”. Mental        Health Law & Policy Faculty Publications. Paper 268.

Steadman, Henry., Kostas Gounis., Deborah Dennis., Kim Hopper., Brenda Roche., Marvin      Swartz., Pamela Robbins. 2001. Assessing the New York City Involuntary Outpatient    Commitment Pilot Program. Psychiatric Services, 52 (3) 330-336

Stuart, Heather & Julio E. Arboleda-Flórez.2001. A Public Health Perspective on Violent         Offenses Among Persons with Mental Illness. Psychiatric Services, 52 (5): 654-659

Swartz, Martin., Jeffrey Swanson., Virginia Hiday., H. Ryan Wagner., Barbara Burns., Randy Borum. 2001. A Randomized Controlled Trial of Outpatient Commitment in North     Carolina. Psychiatric Services. 52, (3):325-329

Swartz, Marvin et al. 2009. New York State Assisted Outpatient Treatment Program Evaluation. available at http://www.omh.ny.gov

Teplin, Linda et al. 2005. Crime Victimization in Adults with Severe Mental Illness:     Comparison with the National Crime Victimization Survey, Archives of General      Psychiatry, 62 (8): 911-922

Torrey, E. Fuller. 1994. Violent Behavior by Individuals with Serious Mental Illness. Insight and Psychosis. 45 (7): 653-662

Torrey, E. Fuller & Mary Zdanowicz. 2001. Outpatient Commitment: What, Why and for        Whom? Psychiatric Services. 52 (3): 337-341

Wales, Heatcote & Virginia Hiday. 2006. PLC or TLC: Is Outpatient Commitment the/an         Answer? International Journal of Law and Psychiatry. 29: 451-468

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