Dr. Swanson and Colleagues Reply

To the Editor: We appreciate Dr. Berkeley’s thoughtful letter to the Editor regarding our article. As Dr. Berkeley correctly implies, the legislative intent of outpatient commitment and similar laws is not to authorize punitive interventions or coercion per se . Rather, it is to provide needed mental health services to certain severely mentally ill individuals who may otherwise go untreated to their detriment and that of the community. For example, New York’s assisted outpatient treatment law (also known as Kendra’s Law) requires the state to provide case management services and, more specifically, to “evaluate the conditions or needs of assisted outpatients, to take appropriate steps to address the needs of such individuals, and to ensure compliance with court orders (1) .”

Additionally, as Dr. Berkeley suggests, whether mandated community treatment programs are practically effective in meeting their stated goals is a matter of some dispute, awaiting evidence from further research.

However, we do not agree with Dr. Berkeley that our use of the term “leverage,” as applied to a broad array of treatment mandates from the social welfare and legal systems, necessarily “projects the impression that these mandates are being used to coerce an individual in a punitive manner.”

First, we think that the use of some forms of leverage is better conceived as an offer being made to a person—an offer that he or she can refuse and be no worse off than had the offer not been made—than as a punitive threat (2) . Consider mental health courts, for example, where criminal defendants with mental illness are essentially offered the choice of participating in court-mandated community treatment versus accepting whatever sanction would normally be given by the criminal court.

Second, in our view, the degree of coerciveness associated with leveraged community treatment is properly an empirical question, rather than a matter of semantics. Studies show that some people, indeed, consider it coercive to condition benefits (such as housing or money) on treatment participation, but others do not. For some, coercion is a relative matter, compared with the prospect of involuntary hospitalization, and outpatient commitment may be seen as a far less restrictive alternative (3) . Moreover, many people under involuntary outpatient commitment nevertheless do not consider this to be very limiting in their own daily experience, particularly if they do not also have other forms of leverage applied to them simultaneously (4) . Still other individuals with mental illness do perceive some coercion in their personal experience with leveraged treatment, but nevertheless believe that such interventions are generally fair, effective, and personally beneficial to them (5 – 7) .

Finally, we agree completely with Dr. Berkeley that “without solid outcome measures, it becomes difficult to translate theory into practice.” Improving clinical practice by systematically studying outcomes, building evidence, and doing what works is a worthy goal and, in the area of violence risk management, perhaps a high-stakes endeavor.