Therapeutic jurisprudence and outpatient commitment law: Kendra's Law and case study.

This article considers the implications of assisted outpatient commitment laws (OPC), with specific focus on New York's "Kendra's Law" through the lens of therapeutic jurisprudence (TJ). In this article, the author offers perspectives on the relationship between involuntary civil commitment, outpatient commitment, and the concept of the "least restrictive alternative"; considers pertinent empirical research, and looks at OPC's controversial relationship to forced drugging. Here, the civil libertarian critique is briefly considered, as well as the MacArthur Research Network research. Finally, the author looks closely at Kendra's Law, providing a brief overview of the law itself, and identifying some "pressure points" and pivotal issues, and considers the TJ implications of Kendra's Law, to determine how it "fits" into the public's "take" on all of mental disability law.     

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.     

Civil commitment from a systems perspective

Responsibility for the civil commitment process currently is shared between the justice and mental health systems. Neither system, however, owes substantial loyalty to the goals of civil commitment. The result, as documented in numerous empirical studies, is that the ostensible goals of the process are routinely subverted in favor of other systemic interests. Most reform efforts to date, focused on altering legal rules to conform to doctrinal desiderata, have ignored this problem, leading to uneven and disappointing outcomes. A systems perspective on these problems suggests that one means of dealing with systems whose loyalty to a task is questionable is to create an independent system with the incentives to give primacy to the task in question. The implications of this analysis for civil commitment are explored.     

Does involuntary outpatient commitment lead to more intensive treatment?

Studies of involuntary outpatient commitment (OPC) among persons with severe mental illness have concluded that OPC is only effective in improving treatment outcomes when it is sustained for 6 months or longer and is combined with frequent outpatient services. This article explores factors that influence the delivery of outpatient services to subjects in a randomized trial of OPC and finds 2 general patterns. Outpatient visits were more frequent among all subjects with apparent clinical need, regardless of study assignment, and among subjects whose OPC was sustained beyond an initial court order. These results suggest that, in practice, sustained OPC represents a consensual agreement between clinicians and the court to more intensively address the complex needs of persons with severe and persistent mental illness.     

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.     

Civil commitment in Turkey: reflections on a bill drafted by psychiatrists

Involuntary hospitalization of the mentally ill has been an issue that still remains outside the judicial system in Turkey. Despite the new Turkish Civil Code, which includes several articles relevant to involuntary psychiatric hospital admissions, there still appears to be a need for a comprehensive mental health law to address specific issues concerning civil commitment of the mentally ill. As a result of the lack of specific statutory regulation, an insufficient number of psychiatric hospital beds and limited appreciation of the safety risks involved in untreated mental illness, involuntary hospitalization remains an underutilized option by psychiatrists and the courts alike. In response to its concerned members, the Psychiatric Association of Turkey has appointed a task force to draft a proposed mental health law, entitled the "Psychiatric Patients' Bill of Rights." Although the draft suggests a model with emphasis on the right to psychiatric treatment, it also recommends close judicial oversight to prevent potential abuses of discretion by the system. However, this might present logistic problems in a country with already overburdened courts. Authors discuss the highlights of the draft within the context of Turkey's current cultural, social and judicial structure, and compare it to similar laws of other countries.     

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.