Take Your Medicine Or Else: Outpatient Commitment, Mental Health Courts and Coercion

[Posted by ClinkShrink]

Persuasion is a key element of psychiatric care, even for those who voluntarily seek treatment. Whether it's persuading people to take lithium, to face uncomfortable psychodynamic interpretations or to abstain from drugs and alcohol, psychiatrists often end up in the position of convincing people that it's a good idea to behave in responsible, healthy ways.

Patients have the freedom to choose to accept or reject treatment. It is their choice to live with their symptoms or tolerate medication side effects. This choice only extends so far, however. When a patient's symptoms infringe on the rights or safety of others, persuation may turn to coercion. Initially this pressure to comply with treatment may come from a loved one who has the most immediate contact with the patient or faces the most direct risk. If the patient becomes ill enough to disturb or endanger others, the legal system may intervene to mandate treatment. Civil commitment procedures were formalized in the 1960's and included provisions for hearings, limitations on the length of confinement and requirements for proving dangerousness or disability. More recently, some states have adopted outpatient commitment procedures. For those involved in the criminal justice system, some jurisdictions have specialized mental health parole programs or mental health courts.

Regardless of the specific mandated treatment paradigm, the trigger issue is usually patient's risk of violence. Mental health clinicians should be aware of the most recent, and probably best, research in this area found in the MacArthur Violence Risk Assessment Study. In short, it found that recently discharged civilly committed psychiatric patients without substance abuse problems were no more dangerous than others in their community without mental illness. The strongest risk factor for violence was substance abuse. Clinicians were able to predict violence with some degree of accuracy.