Involuntary outpatient commitment (IOC) targets persons documented as presenting a danger to themselves and/or others, with intent to supply community-based psychiatric care instead of in-hospital treatment.
Two caveats: First, the ‘involuntary’ component, particularly the court-ordered part. Secondly, the availability of appropriate community-based services where the person is based.
In the U.S., 47 states have some form of IOC laws in place. The three holdouts are Connecticut, Maryland and Massachusetts. Now, Massachusetts lawmakers in the state Senate have introduced a bill to institute IOC measures.
The Massachusetts Senate bill, S980, “An Act to Provide Critical Community Services,” follows a previous Senate bill S942, both presented and co-sponsored by Sen. Cindy Friedman (D-4th Middlesex District). The bill would create a new process to commit an individual (age 18 and over) to community help, rather than hospitalization.
Eligibility criteria in Massachusetts includes a history of lack of compliance with previous treatment for mental illness and a finding that the individual is a harm risk to themselves and/or others and/or puts themselves at risk for harm by others.
IOC proponents in Massachusetts say the measure represents the least restrictive mental health alternative. A court would approve a written treatment plan based on input from a community health service entity. When possible, the plan would include wrap-around services such as help accessing medical needs, employment, food, clothing, and shelter.
The headwinds against the Massachusetts initiative come from concern about patients’ autonomy — the ability to refuse court-ordered compulsory treatment, versus harm to the patients or to their community if they go without treatment.
Among its opponents is the Massachusetts-based Disability Law Center. Rick Glassman, JD, director of advocacy, said that the few empirical studies of outpatient commitment programs have reported mixed results.
Conducting a randomized well-controlled study is difficult, he noted in an email, citing a study conducted at Bellevue Hospital in New York City that concluded “outpatient commitment didn’t achieve any statistically significant benefits as compared to intensive but voluntary outpatient treatment.”
Glassman cautioned that almost all well-publicized examples of community violence take place in states with outpatient commitment – “if only because so many states have [IOC].”
Others have reportedly noted the risk of eroding therapist/patient trust if a court becomes involved and treatment becomes compulsory.
The standards the 50 states reveal a wide variety of rulings and protocols on involuntary and court-mandated treatment. Variations among New England states are listed below excepting Massachusetts.
Connecticut currently has no initiative to IOC bills. Kathleen Flaherty, JD, executive director of the Connecticut Legal Rights Project Inc said the CLRP prioritizes supportive housing and other community services over ‘forced treatment’ as a priority. Psychotropic medications help some, but not all, the organization states in an online media sheet, she said, adding that “involuntary medication” limits “fundamental rights and liberty interests.”
Maine has a three-part protocol for its involuntary admission decisions includes a submitted finding by someone in the community – a civilian, law enforcement or other — attesting to behaviors that put an individual at risk to themselves and/or others.
Secondly is a psychiatric evaluation, and lastly, is a court decision based on the findings of the first two. In 2021, Maine updated the forms hospitals must use for IOC, allowing detention for up to 24 hours with a court order for emergency hospitalization in the case of unavailability of a psych bed.
New Hampshire also has a three-part protocol, distinguishing mental illness from impairment caused by epilepsy, intellectual disability, constant or chronic intoxication, and addiction to substances. Additionally, a ‘danger to others’ is established by demonstrating that within 40 days of the petition, the person has posed serious bodily harm to another.
Rhode Island falls on the side of inpatient commitment, requiring a court hearing to demonstrate that the person needs facility-provided care to avoid the ‘likelihood of serious harm’ in the community. The state has programs to divert severely-mentally-ill individuals away from the criminal justice system.
Vermont allows a 72-hour hold for a person in acute mental health crisis before having them involuntarily committed. It also requires a finding of the threat of physical harm to themselves or others or has behaved in such a manner as to indicate inability for self-care. Additionally, it recognizes that if a patient discontinues existing psychiatric treatment, he/she will become a person in need of treatment.