How should we deal with people in our communities who suffer from severe mental illness but do not adhere to the treatment that is offered to them? The question has engendered an intense policy debate on the legitimacy of laws mandating adherence to treatment in the community. Because the debate has been framed as an issue of public safety and the risk of violence, policymakers often select the most coercive form of mandated community treatment — involuntary outpatient commitment — without considering alternative measures to manage risk and promote treatment, and sometimes without knowing whether appropriate care is even available in the community.
Policymakers do face difficult choices as they attempt to balance concerns about public safety, the individual’s right to refuse treatment, and fiscal responsibility. But without a scientific assessment of the field — including the effectiveness and efficiency of alternative approaches — rational discourse is impossible. The Network on Mandated Community Treatment was established to create a scientifically sound evidence base for developing effective policy and practice on whether, and how, to require certain people with mental disorders to adhere to treatment in the community.
Network members represented the fields of psychiatry, psychology, sociology, social work, economics, and law. In its first phase, the Network made a major contribution to the debate by creating a conceptual framework that identified a range of legal, administrative, and social tools that are used as leverage to get people to accept outpatient treatment. In its research, the Network explored the five major forms of leverage described in this framework. The first two work through the social welfare system, the second two through the judicial system, and the last is a form of “self-mandate” for future use.
Money as leverage. Government disability benefits for people with a serious mental disorder are in some cases received and distributed by a family member or other appointed payee. Payees frequently use these payments as leverage to coerce treatment.
Housing as leverage. Because people who depend on disability benefits often can’t afford market-rate housing, government-subsidized housing is used both formally and informally as leverage to ensure adherence to treatment.
Avoidance of jail as leverage. For people who commit a criminal defense, adherence to treatment may be made a condition of probation. This long-accepted judicial practice has become more explicit with the recent development of specialized mental health courts.
Avoidance of hospital as leverage. Under some statutes, judges can order patients to comply with prescribed community treatment, even if the patient doesn’t meet the legal standards for in-hospital commitment. Failure to comply can result in hospitalization.
Advance directives. In some states, a patient can attempt to gain some control over treatment in the event of later deterioration by specifying treatment preferences or a proxy decision maker.
The Network conducted research on how frequently these different types of leverage are used, how the process of applying leverage operates, and what the outcomes are. At the same time, members sought a better understanding of the profound legal, ethical, and political issues raised whenever such leverage is used.
Process and Plans
In its second phase, the Network conducted studies aimed at collecting and evaluating evidence that can be used by policymakers:
Prevalence studies. The Network collected data in five diverse cities, looking at how often given forms of leverage are used, singly or in combination, to get people to adhere to community treatment. They analyzed the data and conducted a follow-up study at one of the sites.
Implementation studies. Through focus groups and open-ended interviews, the team gained an understanding of how different forms of mandated community treatment are put into practice in the real world. They isolated the core dimensions of difference — both within and between different approaches — that may affect outcomes for patients and communities.
Outcome studies. Building on the findings of the implementation studies already completed (on probation, mental health courts, and psychiatric advance directives), the researchers studied the substantive impacts of different forms of mandated treatment on patients, communities, and the health care system. They also looked at long- and short-term economic costs and benefits.