Involuntary Outpatient Commitment

Part One

In 1955, over 559,000 individuals resided in inpatient psychiatric hospitals. By 1995, however, the number had drastically diminished to 69,000, (National Health Policy Forum, 2000). This drastic reduction was largely due to the discovery of antipsychotic medications in the 1950s, and the deinstitutionalization movement of the 1960s, wherein several thousands of mentally ill individuals were released from psychiatric institutions to return to their communities for treatment. Mental health centers (MHCs) were conceptualized during deinstitutionalization to provide treatment to these newly-released mentally ill persons in their communities. Although efforts were well-intended, the MHCs failed to serve the neediest subset of individuals. Instead, they served those who had minor psychiatric diagnoses and needed little treatment. As a result, the United States experienced an increase in the number of homeless individuals, most of whom still exhibited psychotic symptoms. Involuntary Outpatient Commitment (IOC) was created to serve those "forgotten" mentally ill individuals without placing them back in institutions. Ideally, IOC will increase community tenure for the severely mentally ill, decrease the likelihood of decompensation, and provide the necessary treatment by means less restrictive than hospitalization, (Borum et al., 1999).

IOC is a civil procedure whereby a judge orders a person with a mental illness to comply with outpatient treatment within the community, or risk sanctions such as being forcibly brought to treatment by law enforcement officials, (Swartz et al., 2003). The legal authority in IOC is the state's parens patriae power, which provides for the protection of disabled individuals, and its police power, which involves the protection of others. IOC is commonly used for persons with schizophrenia, bipolar disorder, or other psychoses, especially if there is a history of medication non-compliance or repeated inpatient psychiatric admissions, (Torrey & Kaplan, 1995). The national Department of Mental Health receives a certain amount of money each year from the federal government. From this, state mental health departments draw a significant amount of their funds. It is through the state mental health departments that IOC is largely funded. Although IOC is delivered at the local level, those municipalities receive funds from their state mental health department.

IOC was created largely through mandates provided by the Olmstead Act (1999). The Olmstead Act requires public agencies to provide services "in the most integrated setting appropriate to the needs of qualified individuals with disabilities." Further, the act mandates that states place qualified individuals with mental illnesses in community settings, rather than in institutions. Being placed under IOC is contingent upon whether or not such placement is appropriate, affected persons do not oppose such placement, and the state can reasonably accommodate the placement, taking into account resources available to the state and needs of others with disabilities, (The Center for an Accessible Society, 1999). In conclusion, the Olmstead Act provided for the legal groundwork to both provide and enforce IOC.

Research has shown IOC to be more effective when combined with additional components. Examples of these components include psychiatric advance directives, Assertive Case Management (ACM), representative payees, conditional release, conservatorship/guardianship, and mental health courts. Psychiatric advance directives are legal documents that permit mentally ill individuals to authorize and specify treatment in anticipation of future periods of mental incapacity. ACM consists of mental health teams that actively assist with treatment in the home. Representative payees are trusted persons designated by a mentally ill individual that help that individual use funds wisely by being the payee of benefits. Conditional release is when clients are released on conditions that they follow their treatment plan, including taking medications. Conservatorship/guardianship is when a court appoints an individual to make decisions for a legally incompetent individual. Mental health courts offer the mentally ill an alternative to incarceration through supervised treatment, (Torrey, Zdanowicz, Bentley, & Taylor, 2003). While use of all of these components is not necessary or even recommended, utilizing some of them has been shown to increase compliance with treatment.

The process by which IOC is recommended for a client is quite stringent, as it is important to ensure that only the neediest individuals get remanded to IOC. Several criteria must be met before one gets remanded to IOC. These criteria include being age 18 or over, being considered by clinician to be unlikely to survive safely in the community, having a history of treatment refusal that is considered to have contributed to two or more recent hospitalizations or a history of one or more threats or acts of violence to self or to others, and being found unlikely to voluntarily accept, but likely to benefit, from services.

The IOC process begins with the client being the subject of a petition to the court requesting IOC. A number of parties may petition the court for a given individual's outpatient commitment. These parties include directors of public service organizations, parole or probation officers, adult family members, and adult roommates. The petition, along with an affidavit from a physician, is presented to the supreme or county court in the individual's home county. As the law provides, the court then schedules a hearing within three days of receipt of the petition. The court also must notify the subject of the petition of the hearing date and time, but may hold the hearing even if the subject is not present. The individual is entitled to free legal counsel or other counsel at his/her own expense. If he/she has refused to be examined by the physician providing the affidavit, the court may order that the individual be taken into custody and transported to the hospital for this examination.

Once the court finds the subject of the petition eligible, it approves a treatment plan. This plan, submitted by the physician, must include case management and may include any of the following: medication and testing to confirm compliance; individual and/or group therapy; day programming; educational and/or vocational training; treatment and counseling for alcohol or other substance abuse and testing to confirm sobriety; supervised living and any other services that are intended to treat the petitionee's psychiatric disability. The initial commitment is in place for six months, and may be reviewed annually after that point. In the event that an individual with an active commitment chooses