Least Restrictive Alternative Doctrine 175Though initially a recommendation by legal scholars as an alternative to in-
voluntary hospitalization, there has been an increasing focus of late by the legal
field concerning the efficacy of such an option. Two common concerns voiced by
legal scholars are that involuntary outpatient commitment will (1) lead to broader
social control over persons who are not subject to hospitalization and (2) con-
tribute toward the depletion of already-scarce community resources (R. Miller,
1990). Availability of community resources continues to be the primary obstacle to
effective employment of outpatient commitment.Forensic Psychology and Policy ImplicationsThe LRA doctrine, as with most mental health law and policy, is not without
significant controversy. One of the major concerns with the LRA doctrine is similar
to those identified with the criteria for civil commitment. First, the statutes are
imprecise. As Munetz and Geller (1993) note, "physicians and other mental health
professionals are mandated to choose the least restrictive treatment alternative for
psychiatric patients without necessarily understanding what the mandate means or
how to carry it out" (p. 967).
Second, and related to the first, statutes often specify only treatment in the least
restrictive environment. The doctrine's intention was to ensure that hospitalization
occur only as a last resort, when absolutely necessary (Melton ct al., 1987). The
legal concept, however, has essentially been understood as treatment "anywhere
but in the state hospital" (Munetz & Geller, 1993, p. 968). Thus, the treatment
setting has often been the only basis for measurement. In light of this, there is
a presumption that hospitalization is the most restrictive alternative (setting) with
progressively less restrictive settings available (e.g., community). As Melton ct al.
(1987) note, however, such a presumption fails to consider that treatment modalities
are also restrictive. Thus, certain types of treatment in the community may be
more restrictive than the physical constraints of a hospital under different treatment
modes.
For example, is community-based treatment accompanied by long-term psy-
choactive medication less restrictive than hospitalization not requiring the use of
heavy medications? This question alone has been the topic of considerable de-
bate. In fact, in Guardianship of Richard Roc HI (1981) the court noted that it was
unable to answer such a question. Thus, when the issue of least restrictive en-
vironment includes a decision assessing whether forced medication is more of an
intrusion on personal liberty than hospitalization, even the court has not been able to
reach a suitable conclusion. In this sense, treatment modalities are important when
considering the extent of state intervention, the least restrictive of which is the
ideal.
Another important consideration regarding the LRA doctrine was raised by
Arrigo (1993). He notes that decisions regarding the individual's best interest are