Individual Rights Must Be Balanced With `Caring Coercion'

Until just 40 years ago, most people who were seriously mentally ill were coerced and confined (see related article on page 24). The combination of fear and compassion led Western society, through legal and medical means, to restrict the “insane.” Now the majority of people with mental illness reside in the community and receive treatment in the “least-restrictive settings.”

One compelling reason, however, remains for involuntary hospitalization: fear of violence, especially from individuals who are behaving erratically or preoccupied with delusions and lacking a fundamental awareness of their mental illness and their need for treatment. Yet even this fundamental and historical justification for psychiatric coercion is controversial today, clashing with deeply held notions of individual liberty and autonomy.

In recent years the civil rights of mentally ill people have been in the forefront of discussion and debate, in terms of—depending on your point of view—their right to treatment when resources are dwindling or their right to refuse treatment. Society expects psychiatric physicians to exercise good clinical judgment in protecting psychotic patients from themselves or others. Since most inpatient care, including involuntary care, is short term, the issue of coercion has shifted, in part, from involuntary hospitalization to mandatory outpatient treatment.

Mandatory outpatient, or assisted, treatment is court-ordered outpatient care for certain individuals who have a severe mental disorder and do not comply with treatment. It is a preventative approach to trying to avoid not only inpatient care but also the much more deleterious outcome of homelessness and incarceration—the modern epidemic for severely and persistently mentally ill people in America.

As of today, 42 states and the District of Columbia have outpatient commitment statutes, although most of these states implement this authority in a haphazard and inconsistent manner. Assisted treatment has received media attention due to some well-publicized papers on violence in the community committed by mentally ill persons such as Russell Weston, who killed three U.S. Capitol police officers in 1998, and Andrew Goldstein, who pushed Kendra Webdale onto the subway tracks in New York.

The Goldstein case led to the passage of “Kendra's Law,” establishing mandatory outpatient treatment in New York (Psychiatric News, August 19). Recent data from the New York State Office of Mental Health on the first five years of implementation of Kendra's Law indicated that of those participating (several thousand individuals), 77 percent fewer experienced hospitalizations.

In New York there is widespread acknowledgement that this law, despite the protests from some civil libertarians, has been an outstanding example of what I would term “caring coercion.”

A randomized, controlled study in North Carolina found that patients who received intensive routine outpatient services without a court order did not lead to reduced hospital admission rates. But when patients were given the same level of services (at least three outpatient visits a month, with a median of 7.5 visits a month) combined with assisted treatment of six months or more, hospital admissions were reduced by 57 percent and the length of stay by 20 days, compared with individuals without court-ordered treatment.

Despite the above findings, outpatient commitment, or assisted treatment, remains controversial, and currently there is no such law in Maryland, where I live and work.

Another example of “caring coercion” is mental health courts. These courts use their judicial authority to impose treatment compliance as a condition of release from jail or bail or as an alternative to jail. Failure to comply results in the imposition of sanctions up to and including incarceration. The court-ordered treatment alternatives are another example of trying to deal with the number of people with severe mental illness caught up in the criminal justice system.

One of the great tragedies of modern psychiatry is the large number of incarcerated individuals who are mentally ill or drug addicted. This is the inevitable consequence of our reluctance to use caring, coercive approaches such as assisted treatment. A person suffering from paranoid schizophrenia with a history of multiple rehospitalizations for dangerousness and a reluctance to abide by outpatient treatment, including medications, is a perfect example of someone who would benefit from these approaches. We must balance individual rights and freedom with policies aimed at caring coercion. Our responsibility to each other and our respect for personal rights lie at the center of our social and moral choices as Americans. ▪