Until just 40 years ago, most people who were seriously mentally ill were
coerced and confined (see related article on
page 24). The
combination of fear and compassion led Western society, through legal and
medical means, to restrict the “insane.” Now the majority of
people with mental illness reside in the community and receive treatment in
the “least-restrictive settings.”
One compelling reason, however, remains for involuntary hospitalization:
fear of violence, especially from individuals who are behaving erratically or
preoccupied with delusions and lacking a fundamental awareness of their mental
illness and their need for treatment. Yet even this fundamental and historical
justification for psychiatric coercion is controversial today, clashing with
deeply held notions of individual liberty and autonomy.
In recent years the civil rights of mentally ill people have been in the
forefront of discussion and debate, in terms of—depending on your point
of view—their right to treatment when resources are dwindling or their
right to refuse treatment. Society expects psychiatric physicians to exercise
good clinical judgment in protecting psychotic patients from themselves or
others. Since most inpatient care, including involuntary care, is short term,
the issue of coercion has shifted, in part, from involuntary hospitalization
to mandatory outpatient treatment.
Mandatory outpatient, or assisted, treatment is court-ordered outpatient
care for certain individuals who have a severe mental disorder and do not
comply with treatment. It is a preventative approach to trying to avoid not
only inpatient care but also the much more deleterious outcome of homelessness
and incarceration—the modern epidemic for severely and persistently
mentally ill people in America.
As of today, 42 states and the District of Columbia have outpatient
commitment statutes, although most of these states implement this authority in
a haphazard and inconsistent manner. Assisted treatment has received media
attention due to some well-publicized papers on violence in the community
committed by mentally ill persons such as Russell Weston, who killed three
U.S. Capitol police officers in 1998, and Andrew Goldstein, who pushed Kendra
Webdale onto the subway tracks in New York.
The Goldstein case led to the passage of “Kendra's Law,”
establishing mandatory outpatient treatment in New York (Psychiatric
News, August 19). Recent data from the New York State Office of Mental
Health on the first five years of implementation of Kendra's Law indicated
that of those participating (several thousand individuals), 77 percent fewer
In New York there is widespread acknowledgement that this law, despite the
protests from some civil libertarians, has been an outstanding example of what
I would term “caring coercion.”
A randomized, controlled study in North Carolina found that patients who
received intensive routine outpatient services without a court order did not
lead to reduced hospital admission rates. But when patients were given the
same level of services (at least three outpatient visits a month, with a
median of 7.5 visits a month) combined with assisted treatment of six months
or more, hospital admissions were reduced by 57 percent and the length of stay
by 20 days, compared with individuals without court-ordered treatment.
Despite the above findings, outpatient commitment, or assisted treatment,
remains controversial, and currently there is no such law in Maryland, where I
live and work.
Another example of “caring coercion” is mental health courts.
These courts use their judicial authority to impose treatment compliance as a
condition of release from jail or bail or as an alternative to jail. Failure
to comply results in the imposition of sanctions up to and including
incarceration. The court-ordered treatment alternatives are another example of
trying to deal with the number of people with severe mental illness caught up
in the criminal justice system.
One of the great tragedies of modern psychiatry is the large number of
incarcerated individuals who are mentally ill or drug addicted. This is the
inevitable consequence of our reluctance to use caring, coercive approaches
such as assisted treatment. A person suffering from paranoid schizophrenia
with a history of multiple rehospitalizations for dangerousness and a
reluctance to abide by outpatient treatment, including medications, is a
perfect example of someone who would benefit from these approaches. We must
balance individual rights and freedom with policies aimed at caring coercion.
Our responsibility to each other and our respect for personal rights lie at
the center of our social and moral choices as Americans. ▪