Investigators' and judges' opinions about civil commitment

As part of our work with the Oregon Task Force on Civil Commitment, we surveyed the judges and commitment investigators involved in the state's involuntary treatment program. In Oregon the investigators recommend whether or not a commitment hearing should be held. These mental health professionals indicated that current confidentiality laws restrict their access to important information. The investigators also expressed concern about the lack of resources with which to divert clients out of the commitment system. Judges too felt that relaxing the rules of evidence would improve the quality of commitment hearings. Regarding changes in the system, investigators and judges indicated that outpatient treatment (including compliance with medications) should be required of committed patients. These professionals noted that involuntary outpatient treatment could only be enforced if the system included a mechanism for hospitalizing patients who were noncompliant. Although the investigators believed commitment criteria should be broadened so that their clients could receive treatment before becoming dangerous, judges did not generally endorse this view. We discuss the implications of these findings for new civil commitment legislation.     

Involuntary outpatient commitment.

This article offers a novel approach to outpatient commitment (OPC). After distinguishing 4 varieties of OPC, the article shows how 3 are easy to justify, whereas "preventive outpatient commitment" (POC) requires more careful scrutiny. The article argues that, as a general matter, POC is not justified, except for on a "one free shot" basis. The hope is that patients will come to appreciate the benefits of treatment in the community and will become voluntarily compliant; after one free shot, they are in a much better position to decide. The consequences of noncompliance are also explored.     

Dangerousness of civil commitment candidates

This study followed a large, statewide sample of civil commitment candidates both in and out of the hospital for 6 months following their postcourt hearings to determine their postcourt dangerousness. It objectively measures dangerousness by dividing it into five legal components of behavior: (1) type, (2) object, (3) frequency, (4) weapon/means, and (5) severity of outcome. Using data from ward charts, readmission evaluations, recommitment affidavits, and arrest and community mental health center records, it describes candidates' dangerousness in terms of those, five components and compares that dangerousness with the alleged dangerous behavior that brought them into the civil commitment process. It finds that candidates do not tend to be dangerous in the 6 months following their court hearings.     

Exposing the myths surrounding preventive outpatient commitment for individuals with chronic mental illness.

Using New York's "Kendra's Law" as an illustrative vehicle, this article addresses the principal criticisms lodged by opponents of preventive outpatient commitment. The authors argue that preventive outpatient commitment is a useful adjunct to conditional release or placement in the least restrictive alternative that has neither produced revolutionary change in psychiatric commitment standards nor will be used inappropriately to assert governmental control over mentally ill citizens. The authors contend additionally that preventive outpatient commitment does not violate federal constitutional norms or represent bad policy making. The authors acknowledge, however, that the coercion inherent in outpatient commitment schemes may produce certain undesirable side effects. Thus, they explore an alternative approach currently in development in Australia that promotes community-based treatment for chronically mentally ill persons without judicial intervention.     

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND: It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome. AIM: The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion. METHOD: A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered. RESULTS: Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis. DISCUSSION: In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.     

Outpatient civil commitment: a dangerous charade or a component of a comprehensive institution of civil commitment?

This article examines three criticisms frequently directed toward preventive commitment as one form of outpatient commitment. These criticisms contend that preventive commitment (a) abandons the dangerousness criteria for civil commitmnet, (b) promotes unwarranted inpatient commitment of those who do not meet civil commitment criteria, and (c) undermines important individual liberties by diluting the right to refuse treatment. Understanding and evaluating these criticisms requires analysis of the intersection among empirical, conceptual, and justificatory claims. According to the analysis presented here, advocates of preventive commitment can defend a legitimate role for preventive commitment. This analysis applies to preventive commitment as a dispositional alternative within a comprehensive institution of civil commitment involving distinct parens patriae and police power components.     

Involuntary administration of medication in the community: the judicial opportunity

In a state in which patient refusal of antipsychotic medication in all nonemergency situations must be respected, lawyers and psychiatrists in western Massachusetts have employed probate court decisions as involuntary outpatient treatment orders. The legal, administrative, and clinical issues in sustaining court-ordered outpatient treatment are discussed by focusing on case examples demonstrating some successes, some challenges, and some failures. Judicially sanctioned involuntary outpatient treatment presents an alternative model to statutorily based outpatient commitment.     

A comparison of respondents in initial and recommitment hearings

Legislators and researchers have focused on one aspect of civil commitment: initial commitments. Many patients, however, remain in the hospital after their initial commitment expires and, thus, must be recommitted if they are to remain in involuntary treatment. Demographic, clinical, and treatment data were collected on 374 adults having initial or recommitment hearings during a 3-month period at a large state hospital in Virginia. Respondents in initial commitment hearings were younger and displayed acute symptoms; recommitment respondents were older with symptoms of chronic psychopathology, especially those associated with schizophrenia and organic brain syndrome. The subject of recommitment patients and hearings needs to be a focus of future research efforts to determine whether these differences are reflected in a greater relative gap between the letter and practice of the law in recommitment hearings.This research was supported by grant No. R03 MH44065-01 from the National Institute of Mental Health. The financial assistance of the Institute for Research Development of the Human Sciences Research Council is also acknowledged. This article was written while the first author was a postdoctoral fellow in Clinical Services Research, NIMH grant No. 5T32MH17184-06.     

UPHOLDING STUDENTS’ DUE PROCESS RIGHTS: WHY STUDENTS ARE IN NEED OF BETTER REPRESENTATION AT,AND ALTERNATIVES TO,SCHOOL SUSPENSION HEARINGS

Suspension is the most common form of discipline in our schools. In some cases students facing suspension are removed from school for an extended period of time or referred for expulsion based on the findings made at the student's suspension hearing. Nevertheless, students have no legal right to have counsel participate in, or advocate at, suspension hearings. Additionally, schools for the most part do not offer students alternatives to suspension, such as mediation sessions or other programs designed to allow students to complete school or community work while on suspension. This Note discusses the problems associated with school suspension and suspension hearings. It also explains why providing students with legal advocates at suspension hearings will help promote due process and facilitate better decision making on the part of the student. Finally, it advocates for mediation as an alternative to suspension and suspension hearings, as research suggests that mediation would reduce suspension rates and the costs associated therewith.     

REPRESENTING RESPONDENTS UNDER NEW CIVIL COMMITMENT STATUTES: An Analysis of Counsel's Role In and Out of the Courtroom

Using quantifiable attorney behavior measures, instead of outcome measures, both before and during court hearings, this study attempts to evaluate legal representation under reform civil commitment procedures. Counsel representing involuntary commitment respondents full time were well prepared. Court appointed counsel, though better prepared than reported in studies done prior to reform, did not fully investigate their cases. Lack of adequate preparation was associated with a passive role and a non adversary position in court.     

Conformance to Attorney Performance Standards

Legal representation of clients facing involuntary commitment to a maximum security hospital was investigated. Eighty-nine hearings were observed during a 5-week period immediately following implementation of Attorney Performance Standards, which define minimally adequate representation. The 10 participating attorneys reported their preparation for each case, and a summary measure of advocacy was derived. Generally, attorneys engaged in all required activities that could be accomplished in a single preparatory visit to the hospital. The level of advocacy in cases where clients faced civil commitment was compared to cases where the client faced criminal commitment. The unexpected finding that the level of advocacy for civil clients was significantly lower than that for clients facing commitment under any other legal category, was discussed in light of the degree of dangerousness presented by civil clients, the effects of deinstitutionalization, and emerging social policy.     

Fault-lines in community treatment order legislation

This article discusses the major tension points in the legislation that authorises involuntary outpatient treatment for mental disorder in six British Commonwealth jurisdictions. Particular attention is paid to the role of competence (or capacity) principles in the ruling legal criteria, to the precise powers of community treatment conferred, and to the potential impact of the legislation on clinicians' liability concerns. It is argued that the conferral on clinicians of a power to administer 'forced medication' in community settings is not required to promote active use of involuntary outpatient care, and that such a power should not be provided. The article concludes with discussion of the reasons why community treatment orders are used more frequently in some jurisdictions than others.     

The utility of extended outpatient civil commitment

OBJECTIVE: This study considers three hypotheses regarding the impact of extended involuntary outpatient commitment orders on services utilization. METHOD: Service utilization of Victorian Psychiatric Case Register (VPCR) patients with extended (> or =180 day) outpatient commitment orders was compared to that of a diagnostically-matched treatment compliant group with similarly extended (> or =180 day) periods of outpatient care (N=1182)--the former receiving care during their extended episode on an involuntary basis while the latter participated in care voluntarily. Pre/post first extended episode mental health service utilization was compared via paired t tests with individuals as their own controls. Logistic and OLS regression as well as repeated measures ANOVA via the GLM SPSS program and post hoc t tests were used to evaluate between group and across time differences. RESULTS: Extended episodes of care for both groups were associated with subsequent reduced use of hospitalization and increases in community treatment days. Extended orders did not promote voluntary participation in the period following their termination. Community treatment days during the extended episode for those on orders were raised to the level experienced by the treatment compliant comparison group during their extended episode and maintained at that level via subsequent renewal of orders throughout the patients' careers. Approximately six community treatment days were required for those on orders to achieve a one-day reduction in hospital utilization following the extended episode. CONCLUSION: Outpatient commitment for those on extended orders in the Victorian context enabled a level of community-based treatment provision unexpected in the absence of this delivery system and provided an alternative to hospitalization.     

The effects of statutory change on the civil commitment of the mentally ill

Several states have revised their civil commitment statutes in recent years. A majority of the recent revisions reflect judicial directives to provide more explicit commitment criteria, but in some instances, criteria have been broadened in reaction to the difficulty of getting some individuals hospitalized under strict criteria. Such statutory changes have impacted considerably on both process and outcome of the civil commitment system. Adoption of explicit commitment criteria has resulted most visibly in substantial reduction of hospital admissions and census. The present study examines the impact of explicit changes in commitment criteria in Florida following the 1982 enactment of amendments to the Baker Act. A total of 80 commitment hearings are reviewed before and after the law took effect to determine procedural effects of the law on degree of defense counsel advocacy, client dispositions, and on the court's adherence to more explicit criteria. State hospital admissions, discharge, and census information is examined in order to identify the larger impact of 1982 statutory changes on the commitment system. Evidence from hearings and state data suggests that changes in the Florida law impacted significantly on both process and outcome of the civil commitment system. Clients referred to commitment hearings are more dangerous, and may represent a new hard-core group remaining after more explicit eligibility criteria are applied by local intake, and emergency detention facilities. State hospital admissions and census in Florida declined significantly following enactment of the 1982 law, consistent with findings from other states enacting similar statutory reforms. Implications for deinstitutionalization policy and administration are discussed.     

Outpatient commitment: the state of empirical research on its outcomes.

This article briefly describes the historical conditions in the origin and development of outpatient commitment that framed the discourse on its merits and the empirical studies on its outcomes. It divides those empirical studies into two sets on the basis of the questions addressed and critically reviews them. The review pays particular attention to the latest studies that were able to randomize subjects to experimental and control conditions and that were able to offer enhanced services. Finally, this article presents issues not addressed by the empirical studies on outpatient commitment but that need to be addressed in order to understand the choice of using the law to force persons with mental illness to comply with treatment and receive services in the community.     

The effect of witnesses, attorneys, and judges on civil commitment in North Carolina: a prospective study

A total of 388 commitment hearings were observed and analyzed for demographic information on patients, name of judge, duration of hearing, identities of those present and those actually testifying, outcome of any procedural challenges, and concurrence of the judges with attorney and physician recommendations. Age, race, and gender of the patient were found to have no significant effect on the outcome of the cases. Disposition of the cases correlated with recommendations by physicians, witnesses, and state attorneys in an overwhelming number of cases. Possible harmful influences of plea-bargaining in commitment hearings are discussed.     

Outpatient civil commitment in Texas for management and treatment of sexually violent predators: a preliminary report

Texas established in 1999 outpatient civil commitment for sexually violent predators discharged from prison with or without parole. These individuals suffer from a behavioral abnormality, have been convicted of two or more sexually violent crimes and are deemed likely to reoffend. Civilly committed individuals are managed by a team composed of case manager (supervision), treatment provider, public safety officer (global positioning satellite monitoring), and other professionals. Treatment consists of individual and group therapy using a standard workbook. Out of 21 committed individuals, 7 are in the treatment, 1 died, 10 are in custody after breaking conditions of commitment that constitute a felony, and 3 await release from prison. Cost of outpatient civil commitment is less than $20,000/person/year compared with more than $100,000 for inpatient commitment in other states. Texas has found outpatient civil commitment to be an effective and relatively low-cost way to protect the public and treat the offender.     

PLC or TLC: is outpatient commitment the/an answer?

The lively debate over mandated community treatment in general and outpatient commitment laws (OPC) in particular has raised many issues. At its core, the debate is over how and to what extent laws should be formulated to persuade, leverage or coerce (PLC) persons with severe mental illness living in the community to comply with medications that mental health professionals believe they need. The alternative to PLC is what we call TLC (tender loving care): a strategy of using benefits - improved patient-centered treatment, entitlements and service delivery, including assertive outreach - rather than penalties or conditions on access to services, to induce compliance. We examine three aspects of the debate: (1) the empirical case for the need for OPC court orders to maintain revolving-door severely mentally ill persons in the community; (2) the normative argument over whether such orders constitute coercion, and, if so, whether that coercion is justifiable; and (3) the incentives such orders create to leverage community providers to augment resources and tailor treatment and services to entice patients to become willing participants in the management of their disorders.     

Delusional infestation/parasitosis and the law: a review

Delusional infestation (DI) is a psychodermatological condition where sufferers falsely believe they are infested with parasites despite all evidence to the contrary. Besides sparse records of suicide and doctors being assaulted or threatened with legal action by DI patients, few studies have looked at the forensic presentation of DI. This study aimed at describing when and why DI appears in the courtroom. Westlaw and Google Scholar searchers were conducted for relevant articles and legal cases in the USA containing keywords including delusions, insects, bugs, mites, worms, infested, and parasite. The presentation of DI in the courtrooms was compared to its appearance in the general population. Co-morbidity with other mental disorders and/or drug abuse was common, as were other delusions. Evidence of DI has been used in hearings of competency to stand trial and appeals against involuntary commitment or denial of disabilities benefits. Several DI sufferers had filed lawsuits against those they felt failed to properly treat their ‘infestations,’ but all were dismissed for failure to state a claim. In several cases, children were deemed at risk directly due to their parents’ DI. Increased awareness is needed of DI and its risks, especially for children living with delusional caretakers.     

Civil commitment to outpatient psychotherapy: a case study

Commitment to outpatient psychiatric treatment evolved in the courts to protect patients' right to freedom from compulsory hospitalization. This ruling has been criticized by the psychiatric profession, who prioritize treatment rather than liberty. The following case demonstrates the use of commitment as a therapeutic tool in the psychotherapy of a woman with severe borderline pathology. Although the use of coercion in psychotherapy is controversial, its potential use and its ramifications on transference and countertransference issues are discussed.