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Involuntary outpatient civil commitment (IOC) has received increasing attention and up to forty states have adopted some form of it. IOC was conceived as a less restrictive alternative to involuntary hospital commitment for those persons with a mental illness who may not immediately require inpatient hospitalization, but who are nevertheless non-adherent to voluntary outpatient treatment. Its target is typically the patient with a severe psychiatric disorder who has a history of multiple psychiatric hospitalizations as a consequence of dangerous behavior to either him or herself or other citizens when acutely ill; and who has a history of declining treatment that reduces the risk of dangerousness.

This position paper of the American Association of Community Psychiatrists (AACP) does not encyclopedically examine IOC, but presents a concise point of view that is community-focused. From this vantage, our goal is to aid clinicians, administrators, and policy makers as they make their best possible professional decisions.

Our operational definition of IOC is the process whereby a commitment court, pursuant to a state’s civil commitment laws, orders a person with mental illness to undergo community-based mental health care and related social services in lieu of compulsory institutionalization. IOC is similar to, but distinct from conditional incarceration release by a court. Accordingly, our definition concerns outpatient commitment at the point of commitment hearing, as opposed to after a period of coercive institutionalization (Keilitz I, 1990).

We begin by reviewing the research studying the effectiveness of IOC. From there, we discuss important social and ethical issues that augment these data. Specific recommendations follow.

EFFECTIVENESS:

Our present understanding of IOC’s effect on inpatient utilization is that it reduces total hospital days used. One study reveals that the total number of psychiatric admissions can be reduced when IOC lasts for 180 days or greater and when outpatient services, including case management, average three services per month or greater. With respect to improving compliance to outpatient treatment interventions and reducing the risk of dangerous behavior, IOC’s effect is unclear. There is data to supporting IOC lasting 180 days or greater reducing serious violent behavior for those patients with a prior history of such behavior. Further studies are needed to validate this finding.

SOCIAL AND ETHICAL ISSUES:

In recent years, there has been a focus on creating greater accountability in community mental health. There is increasing tension between efforts to destigmatize psychiatric illness, reduce the overall cost of care, and ensure public safety. The latter has been fueled by some highly publicized episodes of violence by people with mental illness.

Against this backdrop, IOC has received attention as a realistic and fair compromise between institutional care and no care. In our clinical experience, for some consumers, IOC may initiate a trajectory towards engagement and rehabilitation by introducing the consumer to the experience of living in the community in a non-dangerous state. IOC is therefore an attempt to balance public safety with every individual’s right to autonomy, self-determination, and treatment.

Mental health providers, and especially psychiatrists, have always been charged with a role in social control. While public safety must always be addressed and involuntary measures are sometimes necessary, this is a complex role, and it can impede collaboration and relationship-building with patients, especially in an era in which consumer autonomy and empowerment is increasingly important.

Coercive measures can risk widening the social distance between providers of mental health services and consumers. This is especially apropos to people who are poor and/or of color. They have special barriers that limit access to both outpatient treatment and advocacy resources, particularly if they have severe psychiatric disorders. In the case of IOC, it has been argued that this well intended legal procedure can relegate the poor into second class citizenship, wherein IOC can serve a purpose of investigating an individual, rather than improving individual functioning. In this regard, the rights of privacy, autonomy, and free speech could be compromised.

Biopsychosocial outpatient treatment interventions implied in IOC (at its ideal) actually assures the human right to basic necessities such as appropriate financial support, health care, and access to housing. A recently enacted outpatient commitment law in New York is an example of serious effort toward this goal, through mandating the mental health system to provide comprehensive care to the committed individual. However, the ability of the system to deliver those needs, in addition to providing psychiatric rehabilitation, varies from one locality to another. Therefore, where political will is weak and resources are poorly dedicated, IOC will afford little benefit to the individual. Ultimately community improvement will also be ill served, except in the immediate realm of perceived if not true public safety.

Another area of concern involves fiscal considerations, best exemplified by public sector managed care. As managed care’s industrialization of mental health services becomes accepted by more public sector payors, interventions that improve control over production (service utilization) will be refined and expanded. In this scenario, the economics of mental health service delivery can create an environment where clinically well-intended tools such as IOC could be used for control over production rather than necessarily improving an individual’s and a community’s well being. This potential collision between managed mental health care principles and the goals of mental health treatment must be thoughtfully considered when IOC is used. Bursten states that "restriction of liberty must be balanced against a compelling State need." Is the fiscal viability of a managed care corporation a compelling State need?

A final ethical issue concerns the difficulties clinicians can encounter while implementing IOC’s. One aspect of this is a risk of overzealously using IOC in response to perceived medicolegal liability, especially for those viewed as high-risk, like the homeless. Such activity erodes the therapeutic relationship while the clinician also feels like a hostage of the law. Another aspect concerns informed consent to the limits of some commitment laws. Some laws actually have few "teeth." That is, when an outpatient violates commitment obligations, the clinician, may be powerless to enforce inpatient treatment. Simultaneously, there may be no legal duty for the clinician to inform the outpatient about the limits of the clinician’s authority. This has a dual potential: distortion of the clinical role with bluff and overuse of IOC, leading the patient to believe that his or her freedom is actually more restricted than it really is; and under-utilization, as both clinicians and patients realize the system’s inability to enforce commitment.

It is the recommendation of the AACP that the benefits of IOC to the consumer, family, and community be thoughtfully weighed against IOC’s infringement upon the human and constitutional rights of the consumer.

• The AACP recommends that more research is needed concerning IOC’s clinical and rehabilitative benefits and whether this treatment intervention improves public and personal safety. At this time the limited research on the effect of IOC show benefits in reducing hospitalization days. There is tentative evidence of its effect in reducing violence among some individuals. Clinical benefits such as improvement in individual functioning and compliance to outpatient treatment have yet to be shown. The AACP also encourages comparative study between IOC and less coercive treatment tools, such as advanced directives.

• It is the opinion of the AACP that when there is studied consensus among treating clinicians, especially in collaboration with the patient, his or her family, and important community members identified by the consumer, IOC is a beneficial treatment intervention.. From a macro-level perspective, IOC can discourage a community from finding creative ways to support its disabled members and returning them to productivity. Conversely, as clinicians, we have seen IOC paradoxically empower both consumers and their communities to identify unique ways to assist in the consumer’s recovery.

• People in poverty have diminished access to clinical and legal resources and are therefore potentially vulnerable to misuses of IOC. The AACP advocates careful attention to these factors. This must exist on a policy level when contemplating the enactment of IOC or while implementing existing statutes. On a clinical level, cultural competency training can help raise clinician consciousness of the vulnerabilities of many public sector mental health consumers.

• The AACP recommends that states and counties add features to their quality assurance monitors for providers to measure the effectiveness of IOC on adherence to treatment and on IOC’s reduction of dangerous behavior.. IOC must be shown to improve both measures beyond that which can be achieved by less coercive means. The AACP cautions states and counties against implementing IOC where resources for services are insufficient to afford the committed outpatient the highest quality mental health care, as well as access to the basic resources of income support, housing, and physical health care. These localities risk providers’ utilizing IOC inappropriately.

• The AACP recommends that as individual, clinical, and rehabilitation programs implement IOC, they need to set up self-monitoring mechanisms. An overly zealous implementation of IOC at the expense of long-term patient engagement and empowerment has distorting effects on patient-clinician relationships. This effect may hamper a clinical program’s ability to assist in recovery. With this understanding, in carefully selected cases, engagement can actually be enhanced through IOC. Monitoring through continuous quality improvement mechanisms, with IOC’s sparse use as a key indicator, encourages the establishment of clear clinical parameters for clinicians to implement it.

Berg JW, Bonnie RJ, When Push Comes to Shove: Aggressive Community Treatment and the Law, in Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law, Dennis, DL & Monahan, J (eds.), Plenum, New York City, 1996.

Bursten B: Posthospital mandatory outpatient treatment. American Journal of Psychiatry 143(10): 1255-1258, 1986.

Hermann DH: Autonomy, Self Determination, the Right of Involuntarily Committed Persons to Refuse Treatment, and the Use of Substituted Judgment in Medication Decisions Involving Incompetent Persons. International Journal of Law and Psychiatry 13(4): 361-385, 1990.

Hiday VA: Outpatient Commitment: Official Coercion in the Community, in Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law, Dennis, DL & Monahan, J (eds.), Plenum, New York City, 1996.

Hiday VA, Goodman RR: The least restrictive alternative to involuntary hospitalization, outpatient commitment: its use and effectiveness. The Journal of Psychiatry and Law: 81-96, Spring 1982.

Hiday VA, Scheid-Cook TL: A follow-up of chronic patients committed to outpatient treatment. Hospital and Community Psychiatry 40(1): 52-59, January 1989

Hopper K, Regulation from Without: The Shadow Side of Coercion, in Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law, Dennis, DL & Monahan, J (eds.), Plenum, New York City, 1996.

Keilitz I: Empirical Studies of Involuntary Outpatient Civil Commitment: Is it Working? Mental and Physical Disability Law Reporter 14(4): 368-379, Jul-Aug 1990.

Laws of New York, Chapter 408 (S.5762-A), 1999: Kendra’s Law

Lovell AM: Coercion and Social Control: A Framework for Research on Aggressive Strategies in Community Mental Health, in Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law, Dennis, DL & Monahan, J (eds.), Plenum, New York City, 1996.

Munetz M, Grande T, Kleist J, Peterson GA: The effectiveness of outpatient civil commitment. Psychiatric Services 47(11):1251-1253, 1996.

Policy Research Associates, Inc.: Research Study of the New York City Involuntary Outpatient Commitment Pilot Program. Prepared for the New York City Department of Mental Health Mental Retardation and Alcoholism Services. December 4, 1998.

Swanson JW, Swartz MS, Borum R, et al.: Involuntary Outpatient Commitment and reduction of Violent Behavior in Persons with Severe Mental Illness. British Journal of Psychiatry 174:324-331, 2000

Swartz MS, Swanson JW, Wagner HR, et al.: Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?: Findings from a Randomized Trial with Seriously Mentally Ill Individuals. American Journal of Psychiatry 156(12):1968-1975, 1999.

Swartz, MS, Swanson, JW, Hiday, VA, et al.: A Randomized Controlled Trial of Outpatient Commitment in North Carolina. Psychiatric Services 52(3): 325-329, 2001.

When attempting to identify the effectiveness of any intervention, it’s effects must be measurable by accepted techniques. We included studies with subject selection criteria as defined in the introduction and which specifically addressed the effect of IOC on compliance to outpatient treatment, as well as reduction in acute illness or dangerous behavior. Minimally, the studies selected had to address the effect of IOC on readmission rates for the study sample either by a pre-IOC/post-IOC design or comparing an IOC intervention group with a demographically and diagnostically similar group who was not exposed to IOC. The table below reveals the articles that met these criteria. The review was extensive and encompassed all of the literature we could find addressing the impact of IOC.

Results of these studies are the following:

1. In regards to hospitalization, IOC showed a clear benefit on reducing the number of psychiatric admissions for consumers in effectiveness studies within the defined follow-up period. With respect to the two efficacy studies, the results were inconsistent. In the New York study, the IOC group showed a greater number of hospitalizations but the average length of stay for each was short enough to show a reduction in total hospital time within the follow-up period compared to the control group. In the Swartz et al study, IOC for greater than or equal to 180 days, and with outpatient services, including case management averaging greater than three services per month showed a significant reduction in both total hospital admissions and total hospital days. It has therefore been shown in both efficacy and effectiveness studies to date that IOC reduces the overall use of hospitalization.
2. In terms of clinical outcomes, two studies have addressed this question. These are, the efficacy study in New York, and the1989 study in North Carolina by Hiday and colleagues. Both of these studies did not show a clear, definitive impact of IOC on increasing consumer involvement with outpatient treatment, i.e. medication compliance, improvement in overall functioning, reduction in troubling psychiatric symptoms, and reduction in homelessness. However, there was evidence in both studies that consumers followed by assertive community treatment teams continued in treatment longer. Therefore, IOC has not been shown to be effective on improving outpatient treatment involvement, level of functioning, and symptom reduction. Nor has it reduced homelessness. These findings require further studies to state definitively what the impact of IOC is on these clinical measures.
3. In regards to the impact of IOC on arrests for dangerous behavior the efficacy study in New York, the 1989 North Carolina study by Hiday and colleagues, and the study by SwartSwanson and colleagues attempted to address this issue. In the New York and 1989 North Carolina study, IOC did not have an effect on arrests for dangerousness. However, the Swartz study did show a reduction in violent behavior for those clients who had a history of serious assault involving weapon use or physical injury to another person within the preceeding year of IOC. In addition, these clients were on IOC for greater than or equal to six months. Key correlates to violent behavior within the study period were substance misuse and nonadherence to psychotropic medication. This study was limited by: length of time on IOC could not be randomly assigned; persons with a documented history of serious violent behavior upon entry into the study could not be randomly assigned to the control group hence, analysis of the effectiveness of IOC in this group is limited to comparisons between those with shorter versus longer periods of court ordered treatment in the community; and outpatient service intensity was not controlled by the study, but varied according to clinical need and unknown factors. Therefore, there is some evidence that IOC for greater than or equal to six months duration can reduce serious violent behavior when it is associated with reduced substance misuse and adherence to psychotropic medication. No clear effect has been shown on dangerous behavior identified to be more common within the mentally ill community. This issue requires further study for a definitive statement to be made on IOC’s effect on dangerousness in general and on serious violent behavior.
4. The studies in general reveal some of the difficulties in performing research in this area. Some of these limitations are: low generalizability of results from one state to another because implementation of IOC provisions appears uneven, with considerable variations within and between states in their pre-hearing procedures, assigned judicial decision making role, post-hearing procedures and program expenditures; and incomparability of study findings due to differences in follow-up time, outcome measures and subject selection.