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Outpatient “Commitment”: A View From Another Bridge

Harold A. Maio

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Updated February 24, 2004

Updated February 24, 2004
I am not sure what commitment people in the mental health profession have to people who could benefit from outpatient treatment. I read a great deal, however, about the interest of people in the mental health profession to forcibly commit people to mental health treatment, specifically, people with severe psychiatric disorders, but I also read a great deal about people refused services for one reason or another, often budgetary. I suppose one could assume that once a person is legally committed as an outpatient, a mental health provider will be forced to address that person’s medical needs, but I see no assurance that people in need, who are not defined by law as qualifying, will not continue to be ignored. First they will have to be defined, then the services may become available. I am also not sure the law will not be abused, as have most mental health statutes in the past.

Kendra’s Law, a New York State statute forcing treatment upon individuals with serious psychiatric issues, who have a history of self-neglect or acts of violence, was instituted in response to the murder of young woman by a person whose psychiatric needs were severe. Her death was tragic, but she was unfortunately not the only victim in the incident: The man had been repeatedly denied services.

The new law will provide for “involuntary outpatient treatment” for individuals like him. Although most people are interpreting the “involuntary” as applying to the man, my view is from another bridge: A mental health system that had denied services will, through this new law have to provide services to people, now defined by the law, who might have been denied services in the past. Force is a two-edged sword.

In Sweden a woman, a politician of note, was murdered in a department store by another person who had been denied services. She is dead, he is in prison, likely for life. Had the mental health system been forced to provide him with treatment, the death might have been avoided, along with the costs of incarcerating him for life. One can never know, but...

In England, a man discharged from a mental institution late at night with nothing but tram fare, a common mental institution approach, stabbed George Harrison. He, too, will spend the rest of his life incarcerated, though the irresponsible act of abandoning him to the streets has resulted in no charges against the institution. Depriving the man who murdered Kendra of sought treatment has resulted in no charges against the agency or agencies that denied him service. Nor have any charges been levied against the actual individuals who made the decisions.

As an advocate in this area I am in contact with many parents of adult men and women whose abilities to deal with psychiatric illnesses is limited. Many of these parents know that no law presently exists that could force treatment upon their sons or daughters, perhaps provide them with a modicum of stability, but I know as well, that no mental health program exists to provide that treatment if it were actually sought, because no one has provided for the costs of implementing it.

Abandoning people to the streets, one of the consequences of “de-institutionalization”, an interesting metaphor, has resulted in moving much mental health treatment to jails and the streets. As people did not choose to be in institutions, so they did not choose the streets. Some might very likely have been unable to choose. No, I do not oppose the closing of the warehouses, but they have not been replaced with sufficient options in the community, though some are developing. Strangely they are developing through agents other than mental health systems, some directly through the advocacy of parent groups. Some are aimed at people who do have sufficient control over their illnesses to monitor their own recovery, and some are designed for people who require continued support to succeed in the community. Each new program is a welcome addition to the broad array of necessary services.

I am a board member of one new program in Florida, initiated by parents, and this year seeking legislative authority. It is called “Self Directed Care”, and as the name implies, is aimed at finding people able to self-direct their recovery. Shortly after the program began, it reached its capacity of 100 participants. Soon it will expand to another region of the state, it is presently only in Jacksonville, and we will see if the integrity of the model can be maintained.

The program is unique in that participants (no not "clients', "patients" or some other euphemism, they are full participants) actually control the dollars provided for their recovery and choose who will provide services. It is not a facility-based program, cutting costs, and force is not an option.

How does one design a program involving force that is both medically and legally ethical? Such a program already exists.

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