The Case for Outpatient Commitment

, After decades of proving its value in treating substance use disorders, the recovery model has been increasingly applied by mental health care providers and consumers to mental illness in general. However, in some states, such as California, tension has arisen between those espousing the recovery model but opposing the involuntary-commitment aspect of assisted outpatient treatment (AOT) and those accepting it.

California's “Laura's Law” allows for AOT in certain circumstances. Those who oppose involuntary treatment believe that it has a negative effect on the mind set of both the patient/consumer and the clinician who prescribes it. They say it interferes with the patient/consumer's self-definition, self-esteem, and self-growth and makes the clinician more authoritarian and less collaborative.

There are a number of us, including many in California, who do not agree with this and point to New York, where little opposition exists after several years' experience with a similar AOT (“Kendra's Law”). The debate is present in many states, and we note that the National Alliance on Mental Illness and the families of serious, persistently mentally ill patients do not, as a group, oppose AOT either. They want their family members in treatment.

The recovery model conceptualizes mentally ill individuals as not only having a brain disorder, but a disorder involving the person's social and psychological being as well. The recovery model theory agrees that brain disorders make patients vulnerable to stresses of daily living, but that the plasticity of the brain allows the corrective milieu to have a powerful recovery influence. Thus, the model emphasizes the social and psychological aspects of mental illness along with the physical. Medications are of great value but are more limited in their effects, directed more toward symptom improvement than interpersonal and occupational functioning. Therefore, the recovery model adds to medication group and/or individual psychotherapy, psychoeducation, work with families and networks, interpersonal and occupational skills training, and so on. Autonomy, empowerment, and involvement are essential parts of the model.

We believe there is general agreement on these recovery-model principles. The disagreement develops when acute psychotic episodes develop. Involuntary treatment during these episodes means some loss of freedom. Yet we ask, Is“ freedom” defined as freedom from the illness or freedom for the illness to take over the individual? Breaks with reality, such as hallucinations and paranoid ideation, too often result in the person's being a danger to self or others or incapable of self care. Is there a double standard in the care of those patients with brain disorders such as Alzheimer's, strokes, brain tumors, and so on that manifest in mental illness symptoms? Would society refuse to use involuntary care for an Alzheimer's patient who is unable to care for himself or herself or is a danger to self or others?

Although no system is perfect, we are impressed with the results in New York state since the advent of Kendra's Law. It authorizes the use of involuntary treatment during acute psychotic episodes. It allows for action that might appear as loss of “freedom” since external restraint is imposed when the individual is in imminent danger of harm to self or others. It satisfies the criteria of “gravely disabled” and“ inability to survive in freedom.” But only that and no more. Thus, these provisions protect individuals with mental disorders against some effects of acute psychotic brain disorder.

New York's AOT law was supported by many families of people with mental illness as a way to help during the illness's acute phase. The law protects the patient and gives support to begin the recovery process. The family of Andrew Goldstein, a man with schizophrenia who pushed Kendra Webdale onto subway tracks, did not want him to stop treatment. If AOT would have prevented that, it would not have been coercing Goldstein but liberating him from the disease to which he was enslaved.

One may sympathize with the sensitivity of individuals with mental illness regarding AOT. But substance abuse disorder “recovereds,” as part of their recovery process, have always recognized the usefulness of external coercion when necessary in the acute phase of their disorders. This acceptance that they are powerless and need help to recover often provides the“ bottom” that counters denial and begins the recovery process. Andrew Goldstein had his freedom from involuntary care, but not freedom from his illness. If this had been reversed Goldstein would not have caused the death of Kendra Webdale. ▪