Debate Over Outpatient Commitment, Involuntary Care

When the National Alliance for the Mentally Ill launched its Treatment Advocacy Center (NTAC) last month, its avowed purpose was to "push for timely and effective treatment for the estimated 2.2 million individuals with severe psychiatric disorders who don't get care when they most need it."

A separate support organization with its own source of funding, NTAC will "support education, research, legal and legislative efforts to promote treatment for individuals with the most serious brain disorders, such as schizophrenia and bipolar disorder."

For some critics, however, the lofty goals are merely a smoke screen for NTAC's main agenda, which is to broaden the state's ability to impose involuntary treatment on unwilling "consumers," including expansion of outpatient commitment programs. While there is broad-ranging support for increased resources for the mentally ill, the degree to which innovations should include mandated care has re-ignited a long-standing debate over whose civil rights are actually being trampled-those individuals who are forced to receive care, or those who are denied care even though they desperately need it.

Determining Treatment Needs

Ron Honberg, NAMI's director of legal affairs and a founding board member of NTAC, said the effort will particularly benefit those who suffer the most from lack of treatment, including individuals who become entangled in the criminal justice system and/or who end up homeless. "There are a number of reasons why people don't have access to treatment, and one of the reasons, at least for a percentage of folks, is that they lack insight about their illnesses and need for treatment," Honberg said. "Humane interventions need to be instituted before people deteriorate to where something horrendous happens."

A patchwork of state laws currently in effect provide for involuntary or court-ordered treatment, but often fail to take into consideration the medical necessities of acutely ill individuals by requiring demonstrations of dangerousness to self or others before care is delivered. Saying that these statutory schemes "don't make sense" and are "neither in the best interest of those individuals nor in the best interests of society," Honberg added that NTAC would be working on a model statute that he hopes will better reconcile treatment needs with respect for civil liberties.

While conceding "these are very complex issues," Honberg said that "most NAMI members feel very strongly that involuntary treatment should be a last resort and that all less onerous options should be tried before involuntary treatment is instituted." Outpatient commitment models offer individuals the ability to retain employment, housing and other benefits within the community, a method preferable to institutionalized care in the majority of cases. Whether a person should be required to take medications or participate in some other treatment plan, however, should be based on mental capacity and medical necessity, rather than on assessments of dangerousness alone, Honberg said.

Compulsory Care Vs. Advocacy

For Wesley Alcorn, the president of NAMI's national consumer council, however, the directed foray into involuntary treatment and commitment policies risks alienating the very people NAMI wants to serve, and detracts from the organization's broader advocacy goals. Describing himself as a pragmatist and a moderate, Alcorn said that those who oppose all forms of compulsory care are just as extreme as those who automatically assume that commitment necessarily equals adequate treatment.

"Our movement is captured between the [2%] on the left and [5%] on the right, and [those minority views] dictate the arguments, and they set the philosophical debates," Alcorn said. "This kind of movement by NAMI [the Treatment Advocacy Center] inadvertently feeds into the worst and it just keeps this polarity going."

Alcorn doesn't deny the need for changes in the law, but said the emphasis on commitment, both outpatient and institutional, and on mandatory medication and treatment plans will only distract attention from broader issues that need to be resolved. For nationwide, comprehensive reform of the mental health systems to occur, issues such as insurance benefits parity, health care system restructuring, voluntary access to community hospitals and care need to be resolved at the same time, he told Psychiatric Times.

"What's ill is the system. The system is broken. Why do we have to tinker around with a broken system when all we're doing is working on symptoms?" Alcorn said. "If we're going to really reform, it needs to be done comprehensively at every level, because what happens when you just fix side effects or symptoms instead of the illness? The illness returns and the patient dies."

Alcorn said that involuntary commitment laws have always been on the books, but that attempting to resolve the problems of the mentally ill by just addressing statutory schemes won't answer most of his concerns. "My questions are these: Commit to where and for how long? Who pays for it? Where do they go when they are released? What's the long-term housing strategy? What's the service delivery system? How do you deal with recidivism?" Alcorn said. "If you can have some kind of commitment strategy that can answer all of those things, and I can be certain that when someone's son or daughter goes into a treatment facility they are going to be treated like a child of God, like a citizen of the United States, and like someone who has intrinsic value, dignity and worth, then you may have something."

Developing New Policy

Despite these concerns, work is already underway to address the ways in which the most desperately mentally ill receive, or don't receive, care. In California, for instance, a coalition of health care professionals, advocates, consumers, public policymakers, corrections and law enforcement officials, and attorneys, acting as private citizens rather than in any of their official capacities, has formed under the aegis of the California Psychiatric Association to tackle reform of the Lanterman-Petris-Short Act (LPS) that currently governs commitment proceedings.

Carla Jacobs, a chair of the LPS task force, hopes that the group can cut through ideological divisions in order to resolve real shortcomings in the law. A member of the boards of NAMI, NTAC and the California Alliance for the Mentally Ill, she rejects the notion that attempting to tackle problems associated with involuntary treatment or commitment will distract NAMI from its traditional course, or that it will hinder efforts to improve the care received by the nation's mentally ill.

"We would like to develop a model statute [that] allows for community recovery for those people who don't have the mental capacity to access treatment for themselves," Jacobs said. "We're trying to divine a public policy that incorporates the newer scientific research on neurobiological conditions and brain ailments, and bring the public policy up to date."