MHANJ Position on Involuntary Outpatient Commitment

Statement of the Problem

The term outpatient commitment refers to a court ordered involuntary commitment regarding either a hospital discharge (typically referred to as conditional release or discharge) or prior to and in order to prevent a hospital admission (typically called initial or preventive outpatient commitment). The commitment may be to a community program and/or a treatment plan that is to be followed in the community. Proposals have been put forward by legislators in 23 states in 1998 in response to public concerns for safety based on highly sensationalized, although infrequent, acts of violence committed by persons with mental illness. At least 51 bills regarding involuntary commitment have been introduced last year with laws related to outpatient commitment enacted in seven of these states. New Jersey has not experienced such a publicized violent event and has not moved, to date, toward introducing an outpatient commitment law. However, public concerns exist on several fronts in New Jersey. Society is greatly influenced by media portrayals of violent events, by fears that those with mental illness are violent or are sexual predators, and by the belief that “mad is bad” and vice versa. This leads to a desire for more protection for our citizens. Related to the link between mental illness and violence is society’s belief that the major problem is that when people with mental illness refuse to take prescribed medications, they become out of control and dangerous.

The problem is viewed differently by consumers of mental health services and families. Of the five million adults in the nation who experience severe mental illness, nearly half receive absolutely no mental health treatment because there are inadequate resources. Of those who do receive care, many receive services that are infatuate or inappropriate. In New Jersey, consumers meeting at regional forums to discuss OPC unanimously stated that the lack of adequate services, including housing, were the major barriers to their maintaining themselves effectively in the community. Families express great concern about the safety a need for services for their sick relative. There are at least three different messages here; the public is saying “Protect me from violent people!” consumers are saying “Why isn't more being done to protect and care for me when I'm sick?” and families are saying, “Protect my sick child!” There is a common thread here of seeking public protection related to mental illness. The MHANJ shares the concern that not enough is being done to help those with mental illness and their families. However, the association does not believe that outpatient commitment is the approach that will solve the problem.

History and Research

In the early 1980s the MHANJ worked with legislators and other concerned groups to create a Screening/Commitment law that would both protect the rights of consumers and provide necessary inpatient treatment when someone dangerous to self or others or property. The law, passed in 1985, included provisions for the following new services:

1. Mobile crisis outreach in every county;
2. Local hospital screening units to determine need for hospitalization;
3. Inpatient psychiatric units for involuntary patients in local hospitals;
4. Conditional discharge and
5. Rights protections.

Unfortunately, the bill was not adequately funded as it became law, and its policies and programs have had to be gradually implemented over time, as funding has become available. Today, there is still inadequate outreach capacity in many areas of the state.

The most recent and thorough study of outpatient commitment was carried out at Bellevue Hospital in New York City in response to a mandate by the New York legislature in 1995. The study compared two groups of patients with severe mental illness who were both exposed to intensive services; one group was committed to receive services and the other was voluntary. Results indicated that people under court ordered treatment did no better than people in the voluntary program in the categories of rehospitalization, arrests, life and symptomology, and discontinued treatment. A conclusion of the Program was that the court order had “no discernable added value in producing better outcomes.” However, results also showed that the availability and use of intensive services made a positive difference in these same categories.

MHANJ Recommendations

Major problems facing those with mental illness and the society they live in are caused by limited resources for community-based mental health services, including housing. As advocates, we have a responsibility to propose solutions that work. We view outpatient commitment as an ineffective non-solution to the problem of meeting people's needs. It provides a destructive response by appearing to solve the problem while ignoring research that indicates that easy access to appropriate resources, not coercion, is the most effective way to promote public and consumer safety. Furthermore, unless there is a substantial increase in resources to implement an outpatient commitment law, there is a real danger that existing resources would be redistributed to accommodate the new law. This situation would penalize those consumers and their families who voluntarily seek treatment. Outpatient commitment also increases the problem of stigmatizing mental illness by criminalizing ill people to legally force them to comply with treatment.

The MHANJ believes there is an effective solution to these challenges. The components of this solution are listed below.

1. The existing Screening/Commitment Law must be fully funded and implemented so that resources such as mobile crisis outreach are available across the state. These gaps should be identified and a full network of crisis services and outreach put in place.

2. Service providers and mental health administration are responsible for planning and delivering treatment. They should be held accountable for improving services.

3. Emphasis must be placed on improving access to services, developing a broader capacity for outreach and follow up care, improving communication, streamlining and coordinating funding streams and treatment.

4. Effective discharge plans and case management should be fully implemented for people with mental illnesses coming out of hospitals and prisons. This should include the appropriate use of Conditional Release where indicated by statewide validated clinical guidelines which need to be developed.

5. An ongoing public education campaign should be implemented to educate children and adults about the range of mental illnesses and available treatments.

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