Whose Mind Is It Anyway?

Next week brings new debate in the California state Legislature over how to solve an old problem: What to do about adult members of our communities who suffer from debilitating psychiatric illnesses such as schizophrenia but who refuse to accept treatment until they deteriorate to the point of requiring involuntary hospitalization or commit a crime and get arrested.

To some degree, every state has faced this dilemma in the decades after deinstitutionalization, when laws were strengthened to protect the right to refuse psychiatric treatment.

Assemblywoman Helen Thomson (D-Davis) is sponsoring legislation, AB 1421, that would authorize court-mandated treatment in the community, a legal policy adopted in most other states. The law would establish a program called Assisted Outpatient Treatment (also known as involuntary outpatient commitment).

At the heart of a national debate over outpatient commitment lies a legal-ethical tension between respect for individuals’ rights to make their own decisions about medical treatment and the social responsibility to care for people with severe mental disorders--people who, at times, may fail to recognize the gravity of their conditions.

Opposing arguments are heard from two extremes. On one side are civil libertarian legal advocates and representatives for mental health consumer groups who see outpatient commitment as an infringement on constitutionally protected personal freedom. At the other extreme, advocates for outpatient commitment point to rare acts of violence committed by people with untreated psychoses and insist that such people should be forced to “stay on their medications.”

There is ample room for consensus in the middle ground, where the real issue is not whether one favors or opposes any use of legal coercion in community mental health treatment, but for which subgroups it may be beneficial and appropriate, and how should it be applied. Thomson’s bill goes a long way toward addressing these matters while safeguarding citizens’ civil rights.

Whatever one thinks of outpatient commitment as a public policy, it is unfair to reject mandated treatment without considering the larger context of the real limits of a debilitating condition such as schizophrenia--the impoverishment of life’s choices, the loss of chances and constrained self-determination. Coercion compared to what? Autonomy in what sense?

Outpatient commitment offers a less-restrictive alternative to hospitalization. The goal is to ensure that beneficial treatment and case management are maintained consistently, rather than delaying intervention until rehospitalization is required.

Does outpatient commitment work? Our recent study in North Carolina addressed this question with a one-year experiment among 331 people with severe mental illness. Outpatient commitment works in North Carolina assuming two conditions: The court order is extended for a reasonable period of time (six months or more) and regular follow-up is provided with a case manager or therapist. Under these conditions, outpatient commitment is credited with reducing repeat hospitalizations by 57% and reducing violent behavior by about half.

A Rand report has interpreted our results to mean that if a court order and intensive treatment work together, it is difficult to tell if there is any net benefit to outpatient commitment per se. In fact, our study tested the net effect of outpatient commitment as well as the complementary role of intensive services delivery. We found that subjects who were high-intensity service users without outpatient commitment had no better outcomes than their counterparts who received infrequent services or no services at all. Clearly, the court order added something.

We concluded that outpatient commitment can help an individual adhere to a beneficial regimen of psychiatric treatment, and may also influence the mental health service system by getting case managers more invested in outreach, in mobilizing resources and in leveraging more services on behalf of a patient.

Admittedly, outpatient commitment presents thorny dilemmas. Policy decisions about benefits and quality of life involve subjective evaluation. Which is worse: a year under court-ordered treatment or a week in the hospital or three days in jail for vagrancy? Worse for whom? And with whose money? Answering these questions for a whole state is a difficult task but one worth pursuing.

AB 1421 does not represent a panacea, the end of violence or the end of civil rights in California. It wouldn’t affect the majority of people with some form of psychiatric illness. It wouldn’t fix a fiscal crisis that threatens to further shrink resources for mental health services. But the proposed law does offer a reasonable and measured policy that could make effective treatment much more consistently available to many people.