Ethical and Legal Issues 735
Inpatient Commitment
The MacArthur Coercion Study (MacArthur Research Network on Mental Health
and the Law, 2001b) found that half of inpatients who initially reported that they
didn’t need hospitalization and treatment later shifted their views. Looking back,
they realized that they did, in fact, need to be hospitalized. The other half of the
study’s participants continued to believe that they didn’t need hospitalization. Par-
ticipants also noted that family, friends, and mental health professionals’ attempts
to persuade them by using inducements (for example, saying that voluntarily going
along with a hospitalization would give them more control over the process) did not
feel like coercion, whereas attempts to persuade them by the use of force or threats
(such as the threat of involuntary commitment) did feel like coercion. Moreover, pa-
tients were more likely to feel coerced when they believed that they weren’t allowed
to tell their side of the story or when they believed that others weren’t acting out of
concern and with respect for them.
Mandated Outpatient Commitment
Mandated outpatient commitment developed in the 1960s and 1970s, along with
increasing deinstitutionalization of patients from mental hospitals; the goal was to
develop less restrictive alternatives to inpatient care (Hiday, 2003). Such outpatient
commitment may consist of legally mandated treatment that includes some type of
psychotherapy, medication, or periodic monitoring of the patient by a mental health
clinician. The hope is that mandated outpatient commitment will preempt a cycle
observed in many patients who have been committed: (1) getting discharged from in-
patient care, (2) stopping their medication, (3) becoming dangerous, and (4) ending
up back in the hospital through a criminal or civil commitment or landing in jail.
Researchers have investigated whether mandated outpatient commitment iseffective: Are the patient and the public safer than if the patient was allowed to
obtain voluntary treatment after discharge from inpatient care? Does mandated
treatment result in less frequent hospitalizations or incarcerations for the patient? To
address these questions, one study compared involuntarily hospitalized patients who
either were offered psychosocial treatment and services upon discharge or who were
court-ordered to obtain outpatient treatment for 6 months—and made frequent use
of services (between 3 and 10 visits/month) (Hiday, 2003; Swartz et al., 2001). The
results indicated that those who received mandated outpatient treatment:
- went back into the hospital less frequently and for shorter periods of time,
- were less violent,
- were less likely to be victims of crime themselves, and
- were more likely to take their medication or obtain other treatment, even when
the mandated treatment period ended.(Note, however, that patients in this study were not randomly assigned, so there
may have been confounds.) Other studies have found similar benefi ts of mandated
outpatient commitment (Hough & O’Brien, 2005). When people know that they
will end up back in the hospital if they don’t participate in treatment, they are more
likely to comply with that treatment. That said, it is also clear that mandated outpa-
tient commitment is not effective without adequate funding for increased therapeu-
tic services (Perlin, 2003; Rand Corporation, 2001). Let’s examine what happens
without adequate funding.
The Reality of Treatment for the Chronically Mentally Ill
Coercion to be hospitalized was not an issue for Andrew Goldstein. In fact, he had
the opposite problem: He generally wanted to be hospitalized and tried repeatedly
to make that happen.
He signed himself in voluntarily for all 13 of his hospitalizations. His problem was
what happened after discharge. The social workers assigned to plan his release knew
he shouldn’t have been living on his own, and so did Goldstein, but everywhere they
looked they were turned down. They found waiting lists for long-term care at state