Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness

Recent evidence suggests that involuntary outpatient commitment (OPC), when appropriately applied, can improve adherence with psychiatric treatment, decrease hospital recidivism and arrests, and lower the risk of violent behavior in persons with severe mental illness. Presumably these are benefits that improve quality of life (QOL); however, insofar as OPC involves legal coercion, the undesirable aspects of OPC could also exert a negative effect on quality of life, thus offsetting clinical benefits. Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment in the community after hospital discharge, and were followed for one year. Quality of life was measured at baseline and 12 months follow-up. Treatment characteristics and clinical outcomes were also measured.Subjects who underwent longer periods of outpatient commitment had significantly greater quality of life as measured at the end of the 1 year study. Multivariable analysis showed that the effect of OPC on QOL was mediated by greater treatment adherence and lower symptom scores. However, perceived coercion moderated the effect of OPC on QOL. Involuntary outpatient commitment, when sustained over time, indirectly exerts a positive effect on subjective quality of life for persons with SMI, at least in part by improving treatment adherence and lowering symptomatology.     

The effectiveness and ethical justification of psychiatric outpatient commitment

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted involuntarily under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients.     

Qualitätskriterien forensischer Ambulanzen des Strafvollzugs

In 2007 the legal reform concerning the supervision of conduct established forensic aftercare as mandatory for patients released from forensic commitment hospitals and offenders released from penitentiaries. Therefore, in the past 10 years forensic outpatient departments have evolved all over Germany in a state-specific manner according to the legal mandate of treating and managing released offenders. Some of these outpatient departments were newly founded and some were long established units for treating and managing offenders that expanded their services for offenders under supervision of conduct. During the past years these heterogeneous outpatient departments have formed a federal network targeting professional exchange, commonalities, discrepancies and distinct characteristics in realizing the legal mandate. Following the debate on minimum requirements in forensic psychiatric aftercare departments of forensic commitment hospitals in 2014, this federal network developed quality criteria. Despite diverse state and trusteeship-specific conditions, these quality criteria emphasize common content and formal factors for a successful forensic outpatient treatment. This article presents the result of a discussion process along with the agreed quality criteria in the categories of the quality of structure, process and results.     

Does fear of coercion keep people away from mental health treatment? Evidence from a survey of persons with schizophrenia and mental health professionals

Mental health consumer advocates have long argued that involuntary treatment frightens persons with mental disorder and thus deters them from voluntarily seeking help. We surveyed 85 mental health professionals and 104 individuals with schizophrenia spectrum conditions to assess their experience with and perceptions of involuntary treatment and other treatment mandates. Of the clinicians, 78% reported that overall they thought legal pressures made their patients with schizophrenia more likely to stay in treatment. Regarding involuntary outpatient commitment, 81% of clinicians disagreed with the premise that mandated community treatment deters persons with schizophrenia from seeking voluntary treatment in the future. Of the consumer sample, 63% reported a lifetime history of involuntary hospitalization, while 36% reported fear of coerced treatment as a barrier to seeking help for a mental health problem-termed here "mandated treatment-related barriers to care." In bivariate analyses, reluctance to seek outpatient treatment associated with fear of coerced treatment (mandated treatment-related barriers to care) was significantly more likely in subjects with a lifetime history of involuntary hospitalization, criminal court mandates to seek treatment, and representative payeeship. However, experience with involuntary outpatient commitment was not associated with barriers to seeking treatment. Recent reminders or warnings about potential consequences of treatment nonadherence, recent hospitalization, and high levels of perceived coercion generally were also associated with mandated treatment-related barriers to care. In multivariable analyses, only involuntary hospitalization and recent warnings about treatment nonadherence were found to be significantly associated with these barriers. These results suggest that mandated treatment may serve as a barrier to treatment, but that ongoing informal pressures to adhere to treatment may also be important barriers to treatment.     

Effective recruitment of parents into family-focused prevention research: A comparison of two strategies

Abstract

Recent literature highlights the need for more effective recruitment and retention strategies in prevention research. This article reports an investigation of the effectiveness of two recruitment strategies for a family-focused substance abuse prevention study. The first strategy offered prospective participants two points at which they could make a decision about their level of involvement in the research project and required only a limited initial time commitment. The second strategy required an initial commitment to participate in all phases of the project. The investigation was conducted with 208 rural families participating in the pilot phase of a five-year prevention study. There were three primary findings. First, both strategies were effective, yielding higher recruitment rates than would be predicted from relevant literature. Second, the strategy requiring a limited time commitment showed significantly higher rates of recruitment into the pretest, but was associated with significantly lower posttest retention rates. Third, data trends emerged but there were no statistically significant differences between the two recruitment strategy groups across a range of intervention participation indicators.     

"Stereotypic" delusional offending

Some patients with serious mental illness appear to respond violently to the same delusional content throughout the course of their illness. Anecdotal, empirical, and theoretical evidence is presented establishing the premise of "stereotypic" delusional offending. A method for measuring the similarity of two delusions separated in time also is presented. An empirical focus on stereotypic delusional offending may help identify more accurately persons at risk for violence and those at risk for becoming targets of violence. It also may provide a better understanding of successful treatment of outpatient violence and conceivably could inform the ongoing debate on involuntary outpatient commitment laws. Among the major issues of this debate in the United States are the potential benefits of a forced medication provision. One rationale for such a provision may be found in the treatment response of seriously mentally ill outpatients whose violent behavior appears inescapably tied to their persistent or recurrent delusions.     

The reported prevalence of mandated community treatment in two Florida samples

Questions on multiple modes of mandated community treatment (e.g. outpatient commitment, advance directive, representative payee, and special housing) were included in two studies of persons with mental illness, using a mail survey of Medicaid enrollees receiving SSI and interviews conducted as part of an evaluation of a specialty mental health court. Results indicate that the majority of individuals reported no experience with any forms of mandated community treatment. However, respondents from the two samples who had been subject to community mandates reported comparatively similar experiences. Additional studies of the prevalence of mandated community treatment are necessary to garner expanded information regarding the use of such mandates. In addition, future studies must assure that the language employed to query individuals regarding such mandates is clearly understood by respondents, as certain terms (e.g. "outpatient commitment") may mean different things to different respondents.     

Acceptance and commitment therapy and behavioral activation for the treatment of depression: description and comparison

The field of clinical behavior analysis is growing rapidly and has the potential to affect and transform mainstream cognitive behavior therapy. To have such an impact, the field must provide a formulation of and intervention strategies for clinical depression, the "common cold" of outpatient populations. Two treatments for depression have emerged: acceptance and commitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggest largely redundant intervention strategies. However, at other times the two treatments differ dramatically and may present opposing conceptualizations. This paper will compare and contrast these two important treatment approaches. Then, the relevant data will be presented and discussed. We will end with some thoughts on how and when ACT or BA should be employed clinically in the treatment of depression.     

Clients in Treatment for Alcohol Problems: Treatment Experiencesand Outcomes

This report presents an analysis of National Treatment Improvement Evaluation Study data describing the characteristics and treatment experiences of clients entering treatment for alcohol problems. Three client groups were contrasted—those entering treatment for alcohol only, for alcohol plus other drugs, or for other drugs only. Clients using alcohol only were more often white, male, and currently employed. Alcohol only clients were treated predominantly in outpatient settings. Alcohol only clients were frequently referred to treatment by the criminal justice system, and less often self-referred. In all 3 study groups, employment, general health, and mental health outcomes were improved following treatment. Illicit drug use increased marginally for the alcohol only group following treatment. No significant posttreatment reductions in reports of total abstinencefrom alcohol were found for any of the groups. Findings are discussed as they relate to research, treatment practice, and policyareas.     

Hardiness and health: a critique and alternative approach

Recent research has suggested that individual differences in the personality variable of hardiness are related to health and illness. Despite some success at predicting health outcomes, there are several theoretical and empirical problems that must be addressed before research on this topic can proceed. Most critical are (a) how hardiness is to be measured; (b) whether hardiness should be treated as a unitary phenomenon or as three separate phenomena associated with commitment, control, and challenge; and (c) whether hardiness has direct effects on health or indirect effects by virtue of buffering the impact of stressful life events. After reviewing the literature and presenting our own study of the psychometric properties of the Hardiness Scale and its subcomponents, we draw the following conclusions: (a) Hardiness is not a unitary phenomenon, but should be treated as involving three separate phenomena; (b) of the three subcomponents of hardiness, only commitment and control have adequate psychometric properties and are systematically related to health outcomes; (c) lack of control and lack of commitment have direct effects on health because they are psychologically stressful; and (d) if there are buffering effects of commitment and control, they are in addition to these direct effects and are situation specific. Such a systematic consideration of the problems and prospects of the hardiness literature should facilitate research on this important topic.     

Rotting with their rights on: why the criteria for ending commitment or restraint of liberty need not be the same as the criteria for initiating commitment or restraint of liberty, and how the restraint may sometimes justifiably continue after its prerequisites are no longer satisfied

That coerced treatment must end when the criteria for initiating coerced treatment cease to apply appears to be universally accepted by courts and commentators.2 Moreover, the consensus appears to be justified by a steel-trap argument. If coercion is justified only when the patient is mentally ill and incapable, because then the patient lacks autonomous capacities, or lacks practical reasoning abilities that undercut autonomous capacities, then these justifications have no force when the patient either is not mentally ill or is capable. A parallel claim holds for civil commitment. This received wisdom, or in = out thesis, rests upon a conceptual confusion: a failure to distinguish the criteria for initiation of intervention, those for cessation of intervention, and the purpose of the commitment or coerced treatment. If the criteria for commitment were mental illness and dangerousness, and the criteria for release were the same, then the purpose of commitment would be to restore persons to the point where they are either just barely not mentally ill, or just barely not dangerous. That is a silly and self-defeating purpose for that large class of patients who, because of lack of insight, or otherwise, do not become treatment compliant until they are substantially healthier than being barely not mentally ill or barely not dangerous. It sets them up to become revolving-door patients. The purpose of commitment is rather to maximize the patient's mental health, and minimize her dangerousness without unduly burdening her liberty. If society is going to violate a patient's liberty, it should do so in a way that will resolve the problem that justified the restriction on liberty in the first place, so long as the restriction of liberty is not too great in relation to the expected gains from the intervention. The criteria for releasing a patient from commitment are in this way responsive to the purpose of the commitment. For some revolving-door patients, this entails that the criteria for their release from commitment should be stricter than the criteria for initiating commitment in the first place. The criteria for release from commitment for revolving-door patients should be that the criteria for initiation for commitment is not met plus it being more likely than not that the patient will be treatment compliant after release, assuming the additional restriction on liberty is less than the gains from the additional restraint, and the restriction is not unduly burdensome. Spelling this out, the criteria for release should be either not mentally ill, or else not dangerous, or capable, and more likely than not to be treatment compliant after release. For those patients for whom such a test is overly optimistic, we might substitute that there is a reasonable probability of treatment compliance after release, or that the probability of treatment compliance has been enhanced. These criteria are to be thought of as rough and ready rules of thumb, and not as analytically precise tests.     

Fixing forensic patients: Psychiatric recommendations for treatment in pretrial settings

This article is concerned with psychiatric recommendations for treatment at the Metropolitan Toronto Forensic Service (METFORS), a clinical assessment agency providing both 1-day and 30-day evaluations of criminal defendants in Toronto, Canada. Analysis of both psychiatric reports and quantitative research instruments demonstrated the saliency of treatment as a central forensic issue at METFORS. Among a sample of 592 defendants, 134 were considered in need of outpatient care. Persons recommended for hospitalization were most likely to exhibit histories of mental health rather than criminal justice contacts; to be arrested for nonviolent offenses; to manifest psychotic behavior while at METFORS; to be found unfit for bail, incompetent to stand trial, in need of further assessment and dangerous to self; and to experience higher rates of hospitalization, but lower levels of criminalization during the two years following their initial forensic assessment. Psychiatric reports at METFORS tended to merge recommendations for treatment and assessment; to suggest prison or probation as means for securing clinical treatment; and to provide little written support for judgments about the need for intervention. Along with competency and dangerousness, treatment is a key issue in forensic practice, and warrants further attention in the psycholegal literature.     

Goal commitment and the goal-setting process: conceptual clarification and empirical synthesis

Goals are central to current treatments of work motivation, and goal commitment is a critical construct in understanding the relationship between goals and task performance. Despite this importance, there is confusion about the role of goal commitment and only recently has this key construct received the empirical attention it warrants. This meta-analysis, based on 83 independent samples, updates the goal commitment literature by summarizing the accumulated evidence on the antecedents and consequences of goal commitment. Using this aggregate empirical evidence, the role of goal commitment in the goal-setting process is clarified and key areas for future research are identified.     

Inpatient versus outpatient treatment of substance abuse: Recent developments in the controversy

There has been considerable controversy the past decade on which is more effective, inpatient or outpatient treatment of substance abuse. During this same decade substance abuse treatment grew into a $40 billion industry with for-profit hospital programs accounting for as much as one-half the total figure. Recently, controlled studies have replaced the previous research literature which was largely composed of uncontrolled studies. A research consensus is developing that states inpatient rehabilitation has no advantages over outpatient treatment and that even hospitalization for detoxification is unnecessary for 90% of patients. Implications for public policy are that we are over-spending in the treatment of substance abuse by misallocating resources to the most intrusive intervention.Nicholas A. Cummings, PhD, is founder and chairman of the board of directors of American Biodyne and president of the Biodyne Institute, president of the National Academies of Practice, former president of the American Psychological Association, and founder of the four campuses of the California School of Professional Psychology.     

An Open Trial of Acceptance and Commitment Therapy With Exposure and Response Prevention in an Intensive Outpatient Setting for Adults With OCD

Intensive outpatient treatment settings for adults with obsessive-compulsive disorder (OCD) are common, but data on their effectiveness are limited. The effectiveness of IOP treatment for adults with OCD using combined acceptance and commitment therapy (ACT) and exposure and response prevention (ERP) was studied with eight adults. The intervention was 15 hours per week for 3 weeks. Measures were collected at pretreatment, 1-week, 2-weeks, posttreatment, and at 1-month follow-up. At the end of treatment, all participants were in the mild range of OCD symptom severity with a mean symptom decrease of 58%. Psychological inflexibility, depression, anxiety, and stress significantly decreased through treatment and participants ended treatment below clinical range for psychological inflexibility and nonclinical to mild range for depression, anxiety, and stress. The results of this study provide preliminary support for the effectiveness of ACT and ERP in an intensive outpatient setting for adults with OCD. The focus of this paper is on the clinical application of this treatment.     

Forensic follow-up care for outpatients in Germany

Legislation has revived forensic psychotherapy for outpatients in Germany. Since 2007, in almost all 16 federal states of Germany forensic outpatient clinics have been and are being established for criminal and sex offenders who have been released from prison or secure detention under conditions imposed by the court. This paper reviews the consequences of this legislation for forensic outpatients, and will focus on some of the central organisational, institutional and social aspects that stem from the experience of the author. Although the conclusions may not be new, they require repeated reflection and well-considered political commitment.     

The Effect of Interpersonal Trust And Participativeness on Union Member Commitment

Unionized employees have their commitment courted by both their employer and union. They can form a commitment to both, or only one, or neither. It is difficult to predict which commitment might form. It is hypothesized that interpersonal trust and participation attitudes will explain the levels of union commitment formed by union officials. Multiple regression equations and a structural equation model were used to test these hypotheses. Interpersonal trust had a positive yet non-significant effect on union commitment. Participation attitudes had a significant, negative effect on union commitment, opposite that of the hypothesized relationship. The hypotheses are only partially supported.     

A comparison of concurrent and retrospective trajectories of commitment to wed

How well do dating partners recall the development of commitment to wed and what factors modify recall? Motivations underlying recall suggest retrospections should demonstrate one of two patterns, developmental change or amplification. A random sample of 464 partners in heterosexual relationships graphed changes in commitment to wed monthly for 8 months and then graphed them from memory. Results supported the developmental change hypothesis; retrospective reports of commitment initially were lower than concurrent reports and increased more steeply over time. This effect was moderated by changes in relationship stage, with advancement showing accuracy of recall, maintenance showing developmental change, and regression showing amplification. Accuracy of recall depends upon relationship history, which has implications for relationship outcomes and reliability of retrospective reports.     

A comparative study of the behavioral, personality, and fire history characteristics of residential and outpatient adolescents (ages 12-17) with firesetting behaviors

Juvenile firesetting behavior has received relatively little research attention and previous attempts to systematically classify this heterogeneous population of children has been only partially successful. Currently there is no literature available that defines treatment and intervention needs of adolescents in residential treatment with problematic firesetting behavior and whether these needs differ from their outpatient cohorts. Data were gathered from a residential (N=17) and outpatient (N=30) sample detailing firesetting history, behavioral functioning, aggression, and personality traits associated with behavioral difficulties. Study subjects were asked to complete the Youth Self Report (Achenbach), Aggression Questionnaire, and Jesness Inventory and to participate in a structured firesetting history interview by project directors. Parents/guardians were asked to complete a Child Behavior Checklist (Achenbach). Adolescents in residential care were significantly more likely to come from a single-parent home, display increased delinquent behaviors, greater depressive symptoms, and report significantly more aggressive thoughts and attitudes than those in outpatient settings. Few differences were found on personality characteristics associated with behavior and conduct problems and few differences were found relative to fire history and firesetting characteristics. Implications for treatment and intervention within a residential setting are discussed as well as factors possibly associated with delaying and/or avoiding initial residential placement.