The evolution of outpatient commitment in the USA: from conundrum to quagmire

Outpatient commitment (OPC), a major form of involuntary community-based treatment, has evolved in the United States on a state-by-state basis amidst a storm of controversy. The polarizing debate that has gone on intensely about OPC for the last two decades has all too often been devoid of data. This article reviews the various arguments pro and con about OPC, and then examines the research on the effectiveness of OPC. Since the newest data seem to support OPC as a useful tool in dealing with specific subpopulations of persons with chronic mental illness, the paper examines the question of whether OPC is a legitimate use of government power. The most extensive analysis of this question to date has occurred in the New York State Courts which have supported the New York State OPC statute, Kendra's Law. The paper concludes with an examination of the future of OPC in the states, calling in particular for further research into the question of determining to whom, from a clinical point of view, should OPC be delivered.     

The dangerous patient exception to the psychotherapist-patient privilege: the Tarasoff duty and the Jaffee footnote

With the U.S. Supreme Court's 1996 decision in Jaffee v. Redmond, all U.S. jurisdictions have now adopted some form of evidentiary privilege for confidential statements by patients to psychotherapists for the purpose of seeking treatment. The majority of states, following the decision of the Supreme Court of California in Tarasoff v. Regents of the University of California, have also adopted some form of duty by psychotherapists to breach confidentiality and warn potential victims against foreseeable violence by their patients. Largely unresolved is whether there should be a dangerous patient exception to the evidentiary privilege parallel to the Tarasoff exception to confidentiality. This Article argues that exception to the evidentiary privilege should be evaluated separately from the exception to confidentiality. Whether or not a Tarasoff duty to warn existed at an earlier time, exception to the evidentiary privilege should be made only where psychotherapists' testimony is necessary to prevent future harm to patients or identified potential victims. Applying this standard, the dangerous patient exception generally would not apply in criminal actions against patients, but would apply only in proceedings for the purpose of protecting patients or third parties, such as restraining order hearings or proceedings to hospitalize patients.     

History of interpersonal violence, abuse, and nonvictimization trauma and severity of psychiatric symptoms among children in outpatient psychiatric treatment

In a clinical sample of child psychiatry outpatients, chart review data were collected for 114 consecutive admissions over a 1-year period at a Child and Adolescent Outpatient Psychiatry Clinic. Data included history of documented maltreatment, potentially traumatic domestic or community violence, neglect or emotional abuse, and noninterpersonal stressors as well as demographics, psychiatric diagnoses, and parent-rated child emotional and disruptive behavior problems. On a bivariate and multivariate basis, any past exposure to interpersonal violence-but not to noninterpersonal traumas-was related to more severe disruptive behavior problems, independent of the effects of demographics and psychiatric diagnoses. Noninterpersonal trauma and psychiatric diagnoses were associated with emotional problems; exposure to interpersonal violence appeared to partially account for this relationship despite not being independently associated with emotional problem severity. History of exposure to interpersonal violence warrants clinical and research attention as a severity marker and potential treatment focus in psychiatric outpatient services for children, particularly those with disruptive behavior problems.     

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.     

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.