Involuntary Outpatient Commitment Essay

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Involuntary outpatient commitment is a civil procedure in which those who have been deemed in need of mental health services are court-ordered to engage in them in the community. Currently, 42 states and the District of Columbia have laws that permit some form of involuntary outpatient commitment for those who require mental health services, including medication, but who have shown themselves to be noncompliant with treatment regimens in the past. People with chronic and serious mental illness who do not comply with treatment may be at risk of becoming unable to care for themselves, or worse, a danger to themselves or others. The penalty for refusing to comply with an involuntary outpatient commitment order is forced hospitalization. Those who are found to be noncompliant with involuntary outpatient commitment orders are picked up and transferred to a psychiatric hospital for 72 hours, during which time their need for inpatient commitment is determined.

Probably the most famous version of an involuntary outpatient commitment law is Kendra’s Law in New York. More formally known as New York Mental Hygiene Law 9.60(C)-(D), Kendra’s Law was enacted in 1999 and is named after Kendra Webdale, who was killed when Andrew Goldstein pushed her in front of an oncoming train. Goldstein had begged for help for his schizophrenia and checked himself into the psychiatric hospital 13 times since the onset of his illness. He was discharged from his last hospitalization a couple of weeks before pushing Webdale to her death. The hospital was under unrelenting financial pressure to turn patients out after only a few weeks of treatment and Goldstein was discharged, despite the fact that he was very delusional and experiencing other symptoms as well. Similar incidents in New York sparked the development of the law, which permits involuntary outpatient commitment of people who meet a number of criteria, among them having a mental illness, low likelihood of survival in the community without supervision, lack of compliance with treatment for mental illness that has resulted in hospitalization or violence, low likelihood of voluntary participation in mental health treatment, and the necessity of treatment to prevent relapse or deterioration.

Findings on the effectiveness of involuntary outpatient commitment are mixed. Though a number of studies provide evidence that involuntary outpatient commitment is associated with reduced hospitalizations and rearrests, much of this research suffers from serious methodological flaws. Findings from more robust studies that utilize a randomized controlled design are contradictory. A number of studies in North Carolina reveal that involuntary outpatient commitment is associated with significantly reduced likelihood of arrest for those with a history of multiple hospitalizations and arrests or violent behavior and that involuntary outpatient commitment may work to reduce arrests by increasing engagement in mental health treatment and services.

Involuntary outpatient commitment was also shown to reduce rehospitalization in a randomized controlled trial in North Carolina, but only when intensive mental health services were available and provided to those court-ordered to receive them. However, those under involuntary outpatient commitment in North Carolina perceived significantly more coercion than those who were not. A study conducted in New York found no difference between those who were randomly assigned to involuntary outpatient commitment and those who were not on a number of outcomes, including arrests, rehospitalizations, quality of life, and perceived coercion. Given the contradictory nature of these findings, many scholars have concluded that there is not sufficient evidence to determine whether involuntary outpatient commitment is effective at reducing arrests and hospitalizations and improving quality of life.

Even though involuntary outpatient commitment is relatively rarely used, it is one of the most hotly debated ways of mandating mental health treatment in the community. A host of ethical issues surround this practice and advocates and critics take opposing positions.

Advocates for Involuntary Commitment

Advocates for involuntary outpatient commitment argue that it is just one way to encourage compliance with community-based mental health treatment (others include advanced directives, assertive case management, representative payees, conditional release, conservatorship or guardianship, and mental health courts), but that it is necessary for those people who are severely mentally ill and lack insight into their illness. Critics claim that there is little evidence that involuntary outpatient commitment produces positive outcomes, and that when positive outcomes are observed, they appear to be due to the provision of intensive mental health services and not necessarily due to the court order to engage in treatment. Moreover, critics take issue with the notion of lack of insight as a criterion, even an informal one, for involuntary outpatient commitment, claiming that legal standards for involuntary outpatient commitment must be very stringent, lest those who do not need it be subjected to it. In response, advocates for involuntary outpatient commitment note that the standards for involuntary outpatient commitment in many states include both need for treatment and dangerousness, which together are strict and render critics’ fears about net widening unjustified.

Critics further claim that involuntary outpatient commitment may make those truly in need of mental health treatment hesitant to seek it because they believe they may one day be coerced into treatment they do not want, including psychotropic medication. Moreover, coercion into treatment may add to the stigma of mental illness. Critics cite research showing the importance of a therapeutic alliance between consumers and mental health professionals in achieving positive outcomes, as well as the opportunity for consumers to participate in decisions about their treatment. They point out that these crucial elements are absent from involuntary outpatient commitment. Advocates challenge this claim, maintaining that the real stigma of mental illness is violence perpetrated by people with mental illness. Being able to provide treatment to those with mental illness, especially those who lack insight into their conditions, may reduce these episodes of violence and thereby reduce the stigma of mental illness. It may also reduce some of the detrimental effects that serious and untreated mental illness can have, including homelessness, victimization, and contact with the criminal justice system. On the point of violence, critics charge that people with mental illness rarely perpetrate violence, so any justification of involuntary outpatient commitment that rests on the preservation of public safety is tenuous.

Critics also note that court-ordering people to mental health treatment may reduce the ability of those who voluntarily seek services to access them. Advocates claim that wider use of involuntary outpatient commitment will reduce the more expensive use of psychiatric hospital stays, freeing up money to create more community-based mental health services, and further argue that those who have been under involuntary outpatient commitments agree in retrospect that the court order was necessary for them to take medication that was in their best interests.

Finally and most important, critics claim that involuntary outpatient commitment may unnecessarily deprive people of their liberty. These fears are not unjustified—the United States has a long and troubled history of institutionalizing those with mental illness with little to no reason or cause. The ease with which people could be institutionalized prompted an overhaul of the procedure in California that culminated in the Lanterman Petris Short (LPS) Act of 1967. The LPS Act made it much more difficult to institutionalize a person with mental illness and many states followed suit. While proponents of the LPS Act believed it preserved the civil liberties of those most likely to lose them, it had some unexpected effects, including making it very difficult to provide treatment to those in need. In part as a result of these effects, advocates of the related practice of involuntary outpatient commitment claim it does not deprive people of their liberties. In fact, providing treatment to those who do not realize their need for it may allow them to live free from their mental illnesses.

In sum, advocates believe that involuntary outpatient commitment is useful and necessary. Perhaps the practice is not ideal, but it is one weapon in a rather limited arsenal designed to provide effective mental health treatment in the community to those who need it. Critics charge that the utility and necessity of involuntary outpatient commitment are very much in question and that there are other and better ways to provide those who need it with mental health treatment. The arguments put forth by each side are strong, and it is likely that the debate about the ethics of this practice will continue well into the future.


  1. Ridgely, M. Susan, John Borum, and John Petrila. The Effectiveness of Involuntary Outpatient Treatment. Santa Monica, CA: RAND, 2001.
  2. Slate, Risdon and W. Wesley Johnson. The Criminalization of Mental Illness. Durham, NC: Carolina Academic Press, 2008.
  3. Swanson, Jeffrey, Randy Borum, Marvin Swartz, Virginia Hiday, H. Ryan Wager, and Barbara Burns. “Can Involuntary Outpatient Commitment Reduce Arrests Among Persons With Severe Mental Illness?” Criminal Justice and Behavior, v.28 (2001).
  4. Swartz, Marvin, Jeffrey Swanson, H. Ryan Wagner, Barbara Burns, Virginia Hiday, and Randy Borum. “Can Involuntary Outpatient Commitment Reduce Hospital Recidivism? Findings from a Randomized Trial With Severely Mentally Ill Individuals.” American Journal of Psychiatry, v.156 (1999).
  5. Swartz, Marvin, H. Ryan Wager, Jeffrey Swanson, Virginia Hiday, and Barbara Burns. “The Perceived Coerciveness of Involuntary Outpatient Commitment: Findings From an Experimental Study.” Journal of the American Academy of Psychiatry and the Law, v.30 (2002).

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