Involuntary outpatient commitment: Supporters and critics weigh in
Tragic events like the shootings at Sandy Hook Elementary School in Newtown, Connecticut and at the theatre in Aurora, Colorado, tend to shine a spotlight on mental illness and effective ways to treat it. At these times, involuntary or assisted commitment is one subject that comes under scrutiny in states where such legislation doesn’t exist. Connecticut and Massachusetts are currently the only New England states that have not approved an involuntary commitment law, although the Bay State does follow the Rogers Order, which allows the courts to mandate medication for an individual unable to make decisions.
John Mehm, Ph.D., director of the Graduate Institute of Professional Psychology at the University of Hartford, doubts that Connecticut will pass assisted or involuntary commitment legislation. His opinion is based on his experience serving on a task force in 1999 that was convened after a man with mental health problems bludgeoned a parish priest to death in Bristol. “[This event] led to great clamor for involuntary outpatient commitment, so we examined the issue at the time,” he says. Ultimately the state rejected the idea, creating instead a peer engagement specialist program that trains individuals to reach out in a non-coercive manner to those with mental health issues, but who are not undergoing treatment. This tactic operates in the hope the individual will voluntarily decide to seek treatment.
The forcible aspect of involuntary commitment raises ethical concerns for Mehm. “Connecticut is oriented toward recovery, which is not consistent with a coercive element. The research on IOC is somewhat mixed. Some states say it’s helpful in reducing hospitalization and enhancing quality of life. But in many of those states, access to care went along with being committed,” he says. “Connecticut believes the way to help is to increase the number of services. We don’t want to force people to connect. From past experience, I don’t see IOC gaining traction.”
Connecticut does permit involuntary outpatient commitment (also known as assisted outpatient treatment) for an individual considered a danger to self or others as well as for those with a grave disability, according to Mehm. “There will be a push for involuntary commitment in states where that third element is not available.”
Regardless of Connecticut’s decision on involuntary commitment, funding for programs and services can make or break any approach to treatment. Mehm reports that the Department of Mental Health and Substance Abuse was slated for a budget cut in excess of $9 million. “However, that was restored within a month after Sandy Hook,” says Mehm. “The state couldn’t move forward in light of a cut of such proportion to address mental health care. Cutting budgets for mental health and substance abuse services is certainly not the way to go.”
N.H. does have an involuntary commitment statute that allows the state to mandate treatment through New Hampshire Hospital (NHH) when individuals meet the legal criteria for a probate commitment as determined by a judge, according to Elizabeth Howell Woodbury, Psy.D. A psychologist at NHH, she explains that this site is the only designated receiving facility in the state that treats patients on an involuntary commitment. “This relationship between the hospital and the mental health centers in N.H. allows for better continuity of care since the patient always returns to the same hospital for their care,” she says. Judges, NHH and the mental health centers coordinate the legal and clinical aspects of the involuntary commitment, streamlining the process and returning patients to outpatient level of care where possible, adds Howell Woodbury.
In Sept. 2010, the N.H. legislature extended the initial review process for involuntary commitment from 10 days to a 10-day period excluding weekends, thus increasing time for evaluation to a potential 14 days, Howell Woodbury says. “This change standardizes the pre-probate clinical observation period so that it is not dependent on whether the patient comes in on a Friday or during the week. The individual has a few extra days to receive treatment, take medication and become stabilized.”
Contrary to what critics expected, the longer evaluation period has not resulted in an increase in involuntary commitments. Rather, the extension has “allowed us the opportunity to discharge those patients that can stabilize with treatment if given a few extra days, thus they may not need a probate commitment to continue their treatment in the community,” says Howell Woodbury.
Kristina M. Ragosta, Esq., senior legislative and policy counsel for the Arlington, Va. based, Treatment Advocacy Center (TAC), says that assisted outpatient treatment (AOT) laws have become more relevant as states shift care to the community. She believes all discussions should include both inpatient and community-based care and notes that resistance to involuntary commitment often derives from misunderstanding. Ragosta cites four general schools of thought when it comes to opposition. “Common thinking is that if mental health services are robust, a patient will seek help, but this ignores the population being addressed. Many of these individuals don’t believe they are sick, so they don’t seek help,” she says. “Others claim that involuntary commitment drives people away. And some groups oppose assisted treatment because of the potential for abuse. This stems from the history of psychiatric hospitalization in the past. In a proper system of checks and balances and given the number of advocates, there is no reason precautions can’t be taken.”
Claims that involuntary commitment infringes upon a person’s fundamental civil rights and violates the Constitution are completely unfounded. Ragosta says, “This has been tested in the courts and found not to be true.”
DJ Jaffe, executive director of Mental Illness Policy Org., an independent think tank on serious mental illness, emphasizes the importance of funding for these programs. “Assisted outpatient treatment in New York has been estimated to save over $100 million by lowering incarceration and hospitalization costs. In California, it saved $2.52 for every dollar spent. AOT is not only the most effective program for serious mental illness, it is also the most cost-efficient,” he says. “We spend over $100 billion on mental health, but very little on serious mental illness. By prioritizing the most seriously ill, rather than highest functioning, there is more than enough money in the system to implement AOT.”