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The use of outpatient commitment as an alternative to incarceration or inpatient commitment continues to stir controversy, according to panelists at an APA annual meeting workshop titled "Unwelcome Treatment: Treating the Mandated Patient," held in Toronto in June.
There are degrees of coercion in forced outpatient treatment, ranging from forcing a patient to take medication as a condition of freedom, to forcing prisoners to attend treatment against their will, said workshop chair Susan Stabinsky, M.D., acting chief of psychiatry at Lincoln Hospital in the Bronx, N.Y., and president of APA's Bronx District Branch. Most of the mandated patients she has seen were women forced into treatment as a condition of getting their children back. Many of these unwilling patients wished to discontinue therapy as soon as they experienced any improvement but long before the court-ordered term, she said.
The magnitude of the problem is clear, observed Harvey Stabinksy, M.D., J.D., director of education at St. Vincent's Hospital in Harrison, N.Y. From 30 percent to 65 percent of the severely chronically mentally ill are noncompliant within one year of involuntary outpatient commitment, he noted. Among those with schizophrenia, 27 percent to 36 percent are homeless within a year of discharge from a psychiatric facility.
There are, however, distinct advantages to outpatient commitment, he commented. It decreases the need for costly inpatient commitment, fosters long-term recovery and rehabilitation, decreases symptomatology, and protects society by stabilizing potentially dangerous patients who require medication and care. But despite the threat of familial estrangement or legal sanctions, in many jurisdictions success rests mainly on moral suasion.
Although less coercive than inpatient commitment, outpatient commitment is nonetheless coercive and often functions by threatening patients with loss of freedom, he observed. Outpatient commitment violates the patient's right to refuse treatment, which is the law in some states, including New York. It also hinders the development of a therapeutic alliance and carries the potential for abuse.
Many psychiatrists and mental health professionals are as leery of involuntarily committed outpatients as the patients are leery of them. The treatment staff often view coerced treatment as "unwanted, unnecessary, and overly intrusive" and are unenthusiastic about the treatment protocol, said Harvey Stabinksy. This attitude tends to result in treatment failure.
Michael Scimeca, M.D., is director of addiction medicine at St. Barnabas Hospital in the Bronx. Despite patient resistance, evidence suggests that substance abuse patients coerced into treatment stay sober longer than those who voluntarily enter treatment. In this area in particular, familial coercion "has long been recognized as important," Scimeca said.
Because substance-abusing patients are generally rational about other aspects of their lives, coerced treatment can work when the costs of noncompliance and benefits of treatment are clear. Courts often coerce drivers convicted of driving while intoxicated, threatening them with imprisonment or permanent loss of driving privileges for failure to follow treatment. Such programs have been very successful in deterring drunken driving, according to Scimeca.
Pregnant drug abusers may be forced into treatment by family courts and threatened with the loss of their children, which is highly motivating, Scimeca said. The diversion of nonviolent drug offenders into treatment programs rather than prison has been relatively successful. Despite the successes of involuntary outpatient treatment, there are problems. "An awful lot of the patients simply don't want to go," Scimeca observed. "A lot of them see it not as an alternative to incarceration, but the same as incarceration," he noted. Another issue involves perceived authority. Is the judge, the district attorney, or the treatment team in charge?
"Most of us in addiction medicine know it is folly to look at a single dirty urine as treatment failure," since relapse is symptomatic of addiction, Scimeca commented. But the probation or parole officer, who may know little about addiction treatment, may not see it that way.
There is also a "remarkable blind spot" among judges who refer addicted patients for treatment, said Scimeca. The most effective treatment, methadone maintenance, gets the smallest number of referrals and is the least frequently employed aspect of judicially mandated treatment, despite the clear need.
The promise of mandated outpatient treatment for addicts has been eroded by the increase in mandatory minimum sentences for drug crimes, Scimeca observed. It is becoming less of an option to give drug offenders the choice of entering outpatient treatment instead of jail. The trend to mandatory minimums is "so much a matter of politics" and the prevailing social climate rather than good social policy, he added.
There is an inherent contradiction in coerced treatment, observed Kenneth Gilbert, M.D., of Champaign, Ill., who works with imprisoned patients. "I am always uncomfortable" with the possibility that treatment may be serving the ends of the criminal justice system rather than therapeutic goals, he commented.
Since it is likely that coerced outpatients will be more resistant to engaging in a therapeutic alliance than voluntary patients, understanding and overcoming that resistance is a crucial step in therapy, said Ali Khadivi, Ph.D., associate director of psychology at Bronx Lebanon Hospital in the Bronx, N.Y. The therapist must "talk to the resistance" and assume a greater than usual role in motivating change in such patients.
Therapists must clearly distance themselves from the coercing agency, he noted. But they also must clarify issues surrounding confidentiality and boundaries while focusing from the inception on solving specific problems.
One of the greatest hurdles to developing and maintaining the therapeutic alliance is the psychiatrist's dual role as forensic expert and therapist. He or she may have to testify about a patient in court and then turn around and act as that patient's therapist. The best solution, several panelists suggested, is that the therapist avoid testifying about a patient with whom he or she has to develop a therapeutic alliance.
APA published a monograph in 1987 on this topic, titled "Involuntary Commitment to Outpatient Treatment, Task Force Report 26." Copies are available at no charge by contacting Linda Hughes in APA's Division of Government Relations at (202) 682-6227; e-mail: lhughes@psych.org.