Advertisement

Mandated Community Treatment in Services for Persons with Mental Illness

  • Marvin S. Swartz
  • Jeffrey W. Swanson
Chapter

Abstract

This chapter addresses a complex and persistent challenge for mental health services delivery: What to do about adult members of our communities who suffer from debilitating psychiatric illnesses such as schizophrenia but fail to receive consistent and effective treatment. Many are gravely disabled and/or pose a danger to themselves or others, but are often unable or unwilling to adhere to recommended treatment until they deteriorate to the point of requiring involuntary hospitalization or are arrested for a minor crime. Involuntary outpatient commitment—often termed ‘assisted outpatient treatment’—was developed as one potential remedy to address this population of ‘revolving door’ patients. In this civil court procedure, a judge orders a person with mental illness to comply with recommended treatment. We discuss involuntary outpatient commitment in the broader context of mandated community treatment, review the controversies about its effectiveness, the ethics of its use and discuss some potential alternative approaches. Mandated community treatment, if properly targeted and implemented with sufficient resources, can offer a less-restrictive alternative to hospitalization or arrest with the goal of ensuring that beneficial treatment is consistently maintained, rather than delaying intervention until confinement is required.

References

  1. 1.
    Beauchamp, T., & Childress, J. (2012). Principles of biomedical ethics (7th ed.). Oxford: Oxford University Press.Google Scholar
  2. 2.
    Petrila, J., & Swanson, J. W. (2011). Legislating social policy: Mental illness, community, and the law. In N. Cohen & S. Galea (Eds.), Population mental health: Evidence, policy and public health practice (pp. 139–160). New York: Routledge.Google Scholar
  3. 3.
    King, E. F. (1995). Outpatient civil commitment in North Carolina: Constitutional and policy concerns. Law and Contemporary Problems, 58, 251–281.CrossRefGoogle Scholar
  4. 4.
    Swartz, M. S., & Swanson, J. W. (2002). Involuntary outpatient commitment in the United States: Practice and controversy. In Alec Buchanan (Ed.), Care for the mentally disordered offender in the community. Oxford: Oxford University Press.Google Scholar
  5. 5.
    Geller, J. L. (2006). The evolution of outpatient commitment in the USA: From conundrum to quagmire. International Journal of Law and Psychiatry, 29, 234–248.CrossRefGoogle Scholar
  6. 6.
    Roskes, E. (2013). Assisted outpatient treatment: An example of newspeak? Psychiatric Services, 64, 1179.CrossRefGoogle Scholar
  7. 7.
    Miller, R. D. (1988). Outpatient civil commitment of the mentally ill: An overview and an update. Behavioral Sciences & the Law, 6, 99–118.CrossRefGoogle Scholar
  8. 8.
    Geller, J. (2013). Community treatment orders for patients with psychosis. Lancet, 382, 502.CrossRefGoogle Scholar
  9. 9.
    Appelbaum, P. (2001). Thinking carefully about outpatient commitment. Psychiatric Services, 52, 347–350.CrossRefGoogle Scholar
  10. 10.
    Swartz, M. S., & Swanson, J. W. (2008). Outpatient commitment: When it improves patient outcomes. Current Psychiatry Online, 7, 4.Google Scholar
  11. 11.
    Swartz, M. S., Burns, B. J., Hiday, V. A., George, L. K., Swanson, J. W., & Wagner, H. R. (1995). New directions in research on involuntary out-patient commitment. Psychiatric Services, 46(4), 381–385.CrossRefGoogle Scholar
  12. 12.
    Swanson, J. W., & Swartz, M. S. (2014). Why the evidence for outpatient commitment is good enough. Psychiatric Services, 65(6), 808–811.CrossRefGoogle Scholar
  13. 13.
    Swartz, M. S., Wilder, C. M., Swanson, J. W., Van Dorn, R. A., Robbins, P. C., Steadman, H. J., & Monahan, J. (2010). Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatric Services, 61, 976–981.Google Scholar
  14. 14.
    Wagner, H. R., Swartz, M. S., Swanson, J. W., & Burns, B. J. (2003). Does involuntary outpatient commitment lead to more intensive treatment? Psychology, Public Policy and Law, 9(1), 145–158.CrossRefGoogle Scholar
  15. 15.
    Van Dorn, R. A., Elbogen, E. B., Redlich, A. D., Swanson, J. W., Swartz, M. S., & Mustillo, S. (2006). The relationship between mandated community treatment and perceived barriers to care in persons with severe mental illness. International Journal of Law and Psychiatry, 29(6), 495–506.CrossRefGoogle Scholar
  16. 16.
    Van Dorn, R. A., Swanson, J. W., Swartz, M. S., Wilder, C. M., Moser L. L., Gilbert A. R., & Robbins P. C. (2010). Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York. Psychiatric Services, 61, 982–987.Google Scholar
  17. 17.
    Winick, B. J. (2003). Outpatient commitment: A therapeutic jurisprudence analysis. Psychology, Public Policy, and Law, 9, 107–144.CrossRefGoogle Scholar
  18. 18.
    Monahan, J., Bonnie, R. J., Appelbaum, P. S., Hyde, P. S., Steadman, H. J., & Swartz, M. S. (2001). Mandated community treatment: Beyond outpatient commitment. Psychiatric Services, 52(9), 1198–1205.CrossRefGoogle Scholar
  19. 19.
    Swanson, J. W., Swartz, M. S., George, L. K., Burns, B. J., Hiday, V. A., Borum, W. R., & Wagner, H. R. (1997). Interpreting the effectiveness of involuntary outpatient commitment: A conceptual model. Journal of the American Academy of Psychiatry and the Law, 25(1), 5–16.Google Scholar
  20. 20.
    Gerbasi, J. B., Bonnie, R. J., & Binder, R. L. (2000). Resource document on mandatory outpatient treatment. Journal of the American Academy of Psychiatry and the Law, 28(2), 127–144.Google Scholar
  21. 21.
    Swanson, J. W., Van Dorn, R. A., Swartz, M. S., Robbins, P. C., Steadman, H. J., McGuire, T. G. & Monahan, J. (2013). The cost of assisted outpatient treatment: Can it save states money? American Journal of Psychiatry, 170(12), 1423–1432.Google Scholar
  22. 22.
    Swartz, M. S., & Swanson, J. W. (2013). Can states implement involuntary outpatient commitment within existing state budgets? Psychiatric Services, 64(1), 7–9.CrossRefGoogle Scholar
  23. 23.
    Swanson, J. W., Swartz, M. S., & Moseley, D. (2018). Understanding outpatient commitment in context: When is it ethical and how can we tell? In A. Buchanan (Ed.), Care of the mentally disordered offender in the community. New York: Oxford University Press.Google Scholar
  24. 24.
    Buchanan, A., Swanson, J. W., Swartz, M. S., Mosley, D., Kisely, S., & Rugkåsa, J. (2018). Community psychiatric treatment under legal mandates: The international experience. In A. Buchanan (Ed.), Care of the mentally disordered offender in the community. New York: Oxford University Press.Google Scholar
  25. 25.
    Swartz, M. S., Swanson, J., Kim, M., & Petrila, J. (2006). Use of outpatient commitment and similar civil court treatment orders in five United States communities. Psychiatric Services, 57(3), 343–349.CrossRefGoogle Scholar
  26. 26.
    Services Administration (SAMHSA) awards up to $54 million for the assisted outpatient treatment program to help address the need of people who have experienced serious mental illness. https://www.samhsa.gov/newsroom/press-announcements/201609091230. Accessed February 11, 2018.
  27. 27.
    Rosen, M. I., & Rosenheck, R. (1999). Substance use and assignment of representative payees. Psychiatric Services, 50, 95–98.CrossRefGoogle Scholar
  28. 28.
    Cogswell, S. H. (1996). Entitlements, payees, and coercion. In D. Dennis & J. Monahan (Eds.), Coercion and aggressive community treatment. New York: Plenum.Google Scholar
  29. 29.
    Luchins, D. J., Hanrahan, P., Conrad, K. J., Savage, C., Matters, M. D., & Shinderman, M. (1998). An agency-based representative payee program and improved community tenure of persons with mental illness. Psychiatric Services, 49, 1218–1222.CrossRefGoogle Scholar
  30. 30.
    Ries, R. K., & Comtois, K. A. (1997). Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug/alcohol disorders: A comparative study of payee and non-payee participants. American Journal of Addictions, 6, 330–338.Google Scholar
  31. 31.
    Rosenheck, R., Lam, J., & Randolph, F. (1997). Impact of representative payees on substance use by homeless persons with serious mental illness. Psychiatric Services, 48, 800–806.CrossRefGoogle Scholar
  32. 32.
    Hanrahan, P., Luchins, D. J., Savage, C., Patrick, G., Roberts, D., & Conrad, K. J. (1999). Representative payee programs for mentally ill persons in Illinois: Census survey. Presented at the Institute on Psychiatric Services, New Orleans, October 29 to November 2.Google Scholar
  33. 33.
    Korman, H., Engster, D., & Milstein, B. (1996). Housing as a tool of coercion. In D. Dennis & J. Monahan (Eds.), Coercion and aggressive community treatment. New York: Plenum.Google Scholar
  34. 34.
    Matthews, A. (1970). Mental disability and the criminal law. Chicago: American Bar Foundation.Google Scholar
  35. 35.
    Wexler, D. B., & Winick, B. J. (1996). Law in a therapeutic key: Developments in Therapeutic Jurisprudence. Durham, NC: Carolina Academic Press.Google Scholar
  36. 36.
    Watson, A., Hanrahan, P., Luchins, D., & Lurigio, A. (2001). Mental health courts and the complex issue of mentally ill offenders. Psychiatric Services, 52, 477–481.CrossRefGoogle Scholar
  37. 37.
    Steadman, H. J., Davidson, S., & Brown, C. (2001). Mental health courts: Their promise and unanswered questions. Psychiatric Services, 52, 457–458.CrossRefGoogle Scholar
  38. 38.
    Monahan, J., Redlich, A. D., Swanson, J., Robbins, P. C., Appelbaum, P. S., Petrila, J., & McNiel, D. E. (2005). Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56(1), 37–44.Google Scholar
  39. 39.
    Swartz, M. S., Swanson, J. W., Steadman, H. J., Robbins, P. C., & Monahan, J. (2009, June). New York State assisted outpatient treatment program evaluation. Durham, NC: Duke University School of Medicine. Available at https://www.omh.ny.gov/omhweb/resources/publications/aot_program_evaluation/. Accessed February 25, 2018.
  40. 40.
    Swartz, M. S., Burns, B. J., George, L. K., Swanson, J. W., Hiday, V. A., & Borum, R. (1997). The ethical challenges of a randomized controlled trial of involuntary outpatient commitment. Journal of Mental Health Administration, 24(1), 35–43.Google Scholar
  41. 41.
    Petrila, J., Ridgely, S., & Borum, R. (2003). Debating outpatient commitment: Controversy, trends, and empirical data. Crime and Delinquency, 49, 157–172.CrossRefGoogle Scholar
  42. 42.
    Link, B., Castille, D. M., & Stuber, J. (2008). Stigma and coercion in the context of outpatient treatment for people with mental illness. Social Science and Medicine, 67(3), 409–419.CrossRefGoogle Scholar
  43. 43.
    Swartz, M. S., Swanson, J. W., & Hannon, M. J. (2003). Does fear of coercion keep people away from mental health treatment? Evidence from a survey of persons with schizophrenia and mental health professionals. Behavioral Sciences & the Law, 21, 459–472.CrossRefGoogle Scholar
  44. 44.
    Munetz, M. R., Ritter, C., Teller, J. L., & Bonfine, N. (2014). Mental health court and assisted outpatient treatment: Perceived coercion, procedural justice, and program impact. Psychiatric Services, 6(3), 352–358.CrossRefGoogle Scholar
  45. 45.
    Maughan, D., Molodynski, A., Rugkåsa, J., & Burns, T. (2014). A systematic review of the effect of community treatment orders on service use. Social Psychiatry and Psychiatric Epidemiology, 49(4), 651–663.CrossRefGoogle Scholar
  46. 46.
    Kisely, S. R., Campbell, L. A., & O’Reilly, R. (2017). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews (3), CD004408.  https://doi.org/10.1002/14651858.cd004408.pub5.
  47. 47.
    Matter of K.L., 1 NY3d 362 (2004).Google Scholar
  48. 48.
    Torrey, E. F. (2008). The insanity offense: How America’s failure to treat the seriously mentally ill endangers its citizens. New York: W. W. Norton.Google Scholar
  49. 49.
    Swartz, M. S., Swanson, J. W., Wagner, H. R., Burns, B. J., Hiday, V. A., & Borum, W. R. (1999). Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial in severely mentally ill individuals. American Journal of Psychiatry, 156(12), 1968–1975.Google Scholar
  50. 50.
    Swartz, M. S., Hiday, V. A., Wagner, H. R., Swanson, J. W., Borum, W. R., & Burns, B. J. (1999). Measuring coercion under involuntary outpatient commitment: Initial findings from a randomized clinical trial. Research in Community and Mental Health, 10, 57–77.Google Scholar
  51. 51.
    Swanson, J. W., Swartz, M. S., Borum, R. B., Hiday, V. A., Wagner, H. R., & Burns, B. J. (2000). Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry, 176, 324–331.CrossRefGoogle Scholar
  52. 52.
    Swanson, J. W., Borum, W. R., Swartz, M. S., Hiday, V. A., Wagner, H. R., & Burns, B. J. (2001). Can involuntary outpatient commitment reduce arrests among persons with severe mental illness. Criminal Justice and Behavior, 28(2), 156–189.CrossRefGoogle Scholar
  53. 53.
    Swanson, J. W., Swartz, M. S., Elbogen, E., Wagner, H. R., & Burns, B. J. (2003). Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness. Behavioral Sciences & the Law, 21, 473–491.CrossRefGoogle Scholar
  54. 54.
    Swanson, J. W., Swartz, M. S., Van Dorn, R. A., Robbins, P. C., Steadman, H. J., McGuire, T. G., & Monahan, J. (2013). The cost of assisted outpatient commitment: Can it save states money? American Journal of Psychiatry, 170, 1423–1432.Google Scholar
  55. 55.
    Robbins, P. C., Keator, K. J., Steadman, H. J., Swanson, J. W., Wilder, C. M., & Swartz, M. S. (2010). Regional differences in New York’s assisted outpatient treatment program. Psychiatric Services, 61(10), 970–975.CrossRefGoogle Scholar
  56. 56.
    Swartz, M. S., Bhattacharya, S., Robertson, A. G., Swanson J. W. (2016). Involuntary outpatient commitment and the elusive pursuit of violence prevention: A view from the lower 48. Canadian Journal of Psychiatry.  https://doi.org/10.1177/0706743716675857.
  57. 57.
    21st Century Cures Act Public Law No: 114-255 (2016, December 13).Google Scholar
  58. 58.
    Results from the 2011 National Survey on drug use and health: Mental health findings. US Dept. HHS, SAMHSA, Center for Behavioral Health Statistics and Quality. Available at https://www.samhsa.gov/data/sites/default/files/2k10MH_Findings/2k10MH_Findings/2k10MHResults.htm. Accessed February 11, 2018.
  59. 59.
    Pescosolido, B. A., Monahan, J., Link, B. G., Stueve, A., & Kikuzawa, S. (1999). The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health, 89, 1339–1345.CrossRefGoogle Scholar
  60. 60.
    Swartz, M. S., Swanson, J. W., Hannon, M. J., Wagner, H. R., Burns, B. J., & Shumway, M. (2003). Preference assessments of outpatient commitment for persons with schizophrenia: Views of four stakeholder groups. American Journal of Psychiatry, 160, 1139–1146.CrossRefGoogle Scholar
  61. 61.
    Swartz, M. S., Swanson, J. W., & Monahan, J. (2003). Endorsement of personal benefit of outpatient commitment among persons with severe mental illness. Psychology, Public Policy and Law, 9(1), 70–93.CrossRefGoogle Scholar
  62. 62.
    Swanson, J. W., Van Dorn, R. A., Swartz, M. S., Cislo, A. M., Wilder, C. M., Mose, L. L., & McGuire,T. G. (2010). Robbing Peter to pay Paul: Did New York State’s outpatient commitment program crowd out voluntary service recipients? Psychiatric Services, 61, 988–995.Google Scholar
  63. 63.
    Swanson, J., Swartz, M., Van Dorn, R., Monahan, J., McGuire, T., Steadman, H., & Robbins, P. (2009). Racial disparities in involuntary outpatient commitment: Are they real? Health Affairs, 28, 816–826.Google Scholar
  64. 64.
    Szmukler, G., & Kelly, B. D. (2016). We should replace conventional mental health law with capacity-based law. British Journal of Psychiatry, 209(6), 449–453.CrossRefGoogle Scholar
  65. 65.
    Goldman, H. H. (2014). Outpatient commitment reexamined: A third way. Psychiatric Services, 65(6), 816–817.CrossRefGoogle Scholar
  66. 66.
    Halpern, A., & Szmukler, G. (1997). Psychiatric advance directives: Reconciling autonomy and non-consensual treatment. Psychiatric Bulletin, 21, 323–327.CrossRefGoogle Scholar
  67. 67.
    Swanson, J., Swartz, M., Elbogen, E., Van Dorn, R., Wagner, H., McCauley, B., & Kim, M. (2006). Facilitated psychiatric advance directives: A randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness. American Journal of Psychiatry, 163, 1943–1951.Google Scholar
  68. 68.
    Swanson, J. W., Swartz, M. S., Elbogen, E. B., Van Dorn, R. A., Wagner, H. R., Moser, L. A., & Gilbert, A. R. (2008). Psychiatric advance directives and reduction of coercive crisis interventions. Journal of Mental Health, 17(13), 255–267.Google Scholar
  69. 69.
    Swanson, J. W., Swartz, M. S., Hannon, M. J., Elbogen, E. B., Wagner, H. R., McCauley, B. J., & Butterfield, M. I. (2003). Psychiatric advance directives: A survey of persons with schizophrenia, family members, and treatment providers. International Journal of Forensic Mental Health, 2, 73–86.Google Scholar
  70. 70.
    Swanson, J. W., Swartz, M. S., Ferron, J., Elbogen, E. B., & Van Dorn, R. A. (2006). Psychiatric advance directives among public mental health consumers in five U.S. cities: Prevalence, demand, and correlates. Journal of the American Academy of Psychiatry & Law, 34, 43–57.Google Scholar
  71. 71.
    Wilder, C. M., Swanson, J. W., Bonnie, R. J., Wanchek, T. N., McLaughlin, L. R., & Richardson, J. W. (2013). A survey of stakeholder knowledge, experience, and opinions of advance directives for mental health in Virginia. Administration and Policy in Mental Health and Mental Health Services Research, 40(3), 232–239.CrossRefGoogle Scholar
  72. 72.
    American Psychiatric Association. Swartz, M. S., Hoge, S. K., Pinals, D. A., Lee, E., Lee, L. W., Sidor, M., … Johnson, R. S. (2015). Resource document on involuntary outpatient commitment and related programs of assisted outpatient treatment. Available at http://www.psychiatry.org/psychiatrists/search-directories-databases/library-and-archive/resource-documents. Accessed February 25, 2018.
  73. 73.
    Morrissey, J. P., Desmarais, S. L., & Domino, M. E. (2014). Outpatient commitment and its alternatives: Questions yet to be answered. Psychiatric Services, 65, 812–815.CrossRefGoogle Scholar
  74. 74.
    Steadman, H. J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., & Robbins, P. C. (2001). Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services, 52(3), 330–336.Google Scholar
  75. 75.
    Burns, T., Rugkasa, J., Molodynski, A., Dawson, J., Yeeles, K., Vazquez-Montes, M., & Priebe, S. (2013). Community treatment orders for patients with psychosis (OCTET): A randomised controlled trial. Lancet, 381(9878), 1627–1633.Google Scholar
  76. 76.
    Segal, S. P., Hayes, S. L., & Rimes, L. (2017a). The utility of outpatient commitment: I. A need for treatment and a least restrictive alternative to psychiatric hospitalization. Psychiatric Services, 68(12), 1247–1254.Google Scholar
  77. 77.
    Segal, S. P., Hayes, S. L., & Rimes, L. (2017b). The utility of outpatient commitment: II. Mortality risk and protecting health, safety, and quality of life. Psychiatric Services, 68(12), 1255–1261.Google Scholar
  78. 78.
    Gaynes, B. N., Brown, C., Lux, L. J., Ashok, M., Coker-Schwimmer, E., Hoffman, V., & Viswanathan, M. (2015). Management strategies to reduce psychiatric readmissions. Rockville, MD.Google Scholar
  79. 79.
    American Psychiatric Association. (2015). Position statement on involuntary outpatient commitment and related programs of assisted outpatient treatment. Available at https://www.psychiatry.org/psychiatrists/practice/helping-patients-access-care/position-statements. Accessed February 25, 2018.

Copyright information

© The Author(s) 2020

Authors and Affiliations

  • Marvin S. Swartz
    • 1
  • Jeffrey W. Swanson
    • 1
  1. 1.Division of Social and Community Psychiatry, Department of Psychiatry and Behavioral SciencesDuke University School of MedicineDurhamUSA

Personalised recommendations