July 4 juillet 16:00 – 17:45
Room NCDH–101
Chair:
Veena Garyali
, Kirkby Forensic Psychiatric Center,
New York
Discussant: Susan Ridgely , Rand Corporation, Santa Monica, California
Many paradoxes arise in the use of compulsory community care
(or outpatient commitment). For instance, its use may both support and undermine
therapeutic relationships; it may only be appropriate for patients who do not meet its
legal criteria; many patients treated under this form of compulsion are actually
volunteers; family members may support its use in principle, but will not apply
for its use on their relative; when the patient under this form of care avoids
readmission to hospital for an extended period of time, this can be viewed
either as an example of successful use of the order, justifying its
continuation, or as an indicator that the patient should now be discharged.
These and other paradoxes, it will be argued, are a prime reason for the
ambivalence felt by so many participants concerning compulsory community
treatment: e.g., the ambivalence of many patients, clinicians, family members,
lawyers and judges. These thoughts arise from the early stages of qualitative
work on the use of Community Treatment Orders in Otago, in the South Island of
NZ, under New Zealand’s Mental Health Act, directed by Prof Dawson and funded
by the Health Research Council of New Zealand.
This presentation examines the extent to which subjects in a
12-month experimental trial of involuntary outpatient commitment (OPC) felt
coerced and what other demographic, clinical and study year factors predicted
the subjects’ self-reports of coercion. In this study, severely mentally ill (SMI)
subjects were randomly assigned to continue under or be released from
court-ordered OPC following hospital discharge. Subjects with a history of
serious violent behavior were not randomized to release and were followed in a
nonrandomized comparison group. Appraisals of the coerciveness of treatment were examined using
a modified version of the MacArthur Admission Experience Survey (MAES).
Bivariate analyses indicated that significantly higher levels of coercion were
reported by subjects under involuntary outpatient commitment, especially those
who received longer periods of commitment. Multivariable analyses of predictors
of coercion showed higher levels of coercion among subjects with longer periods
of OPC, but also those subjects neither married or cohabiting, with ongoing
co-morbid substance abuse problems, psychiatric hospitalizations during the
study year, or lower intensity of outpatient treatment. Subsequent analyses of
case manager reports of reminders and warnings given to subjects about the
consequences of treatment nonadherence partially accounts for higher subject
reports of the coerciveness of OPC. Previous reports from this study have found
that OPC, if sustained and combined with relatively intensive services, can
improve a number of outcomes. The current analyses demonstrate a clear cost of
OPC in increased subject reports of coercion.
This study reports results from a randomized controlled trial of outpatient commitment on a sample of severely mentally ill persons. Subjects in the control groups were almost twice as likely to be criminally victimized during one year as were the outpatient committed subjects despite both groups’ having case management and individualized treatment plans. Duration of outpatient commitment also impacted criminal victimization, with decreasing odds of victimization associated with increased days on outpatient commitment. These relationships remained statistically significant when other theoretical and empirical predictors of victimization were controlled. We found that outpatient commitment had its effect through improving medication adherence and reducing substance use/abuse.
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