Services Effectiveness Research Program (SERP)

Duke University School of Medicine
Department of Psychiatry and Behavioral Sciences

Current and Recent Projects

Title: Prevalence Study of Leverage in Community Treatment

Sponsor: John T. and Catherine T. MacArthur Foundation for Research Network on Mandated Community Treatment

Principal Investigator(s): Jeffrey Swanson, PhD; Marvin Swartz, MD

SERP Investigators & Collaborators: Richard Van Dorn, PhD; Christine Wilder, MD; Eric Elbogen PhD

Project Description: Much of the strident policy debate on outpatient commitment treats it as if it were simply an extension of inpatient commitment, and views outpatient commitment within the same conceptual and legal framework historically used to analyze commitment to a mental hospital. Increasingly, however, it is becoming apparent that concepts developed within a closed institutional context do not perform as intended in the much less structured context of the open community. To take only one example, in the 1979 case of Addington v Texas, the U. S. Supreme Court raised the standard of proof necessary for the state to invoke inpatient commitment from “preponderance of the evidence” to “clear and convincing evidence.” In reaching this decision, the Court focused on “the individual's interest in not being involuntarily confined,” and held that “civil commitment constitutes a significant deprivation of liberty that requires due process protection.” In the context of outpatient commitment, however, the individual is not being “confined” or “deprived of liberty” at all -- the individual is free to move about as he or she chooses in the open community – as long as periodic office appointments for psychotherapy or medication are kept. Must the state now meet the same heightened standard of proof when it wants to invoke outpatient commitment as the Court 25 years ago said it must to invoke inpatient commitment? Currently available, institutionally-based concepts are not helpful in answering this question and a great many others like it.

Rather than viewing outpatient commitment as a simple extension of commitment to a mental hospital, we propose that outpatient commitment be seen as only one of a growing array of legal tools now being used to insure treatment adherence in the community. It is only in relation to these other forms of “mandated community treatment” that outpatient commitment can be adequately understood and that informed policy decisions on whether to promote or oppose its adoption can be reached. Consider the following examples:

•  People with severe and chronic mental disorders are often dependent upon goods and services provided by the social welfare system. Benefits disbursed by money managers and the provision of subsidized housing are both being used as leverage to assure treatment adherence.

•  Similarly, many discharged patients find themselves arrested for minor criminal offenses. Favorable disposition of their cases by a newly-created mental health court may be tied to treatment participation. In addition, under the outpatient commitment statutes alluded to above, judges have the civil authority to order patients to comply with prescribed treatment in the community.

•  In response to these uses of leverage by officials in the social welfare and judicial systems, patients may attempt to maximize their own control over treatment in the event of later deterioration by executing a psychiatric advance directive that specifies the patient's own treatment preferences or appoints a trusted person as a proxy decision maker. Many view these advance directives as a form of “self-mandated” treatment – a preemptive antidote to being coerced into treatment by others..

The goal of the prevalence study is to obtain descriptive information on how often given forms of leverage -- singly or in combination -- are imposed on people with mental disorder to get them to adhere to treatment in the community. Since we believe that the total amount of leverage used, and distribution of different types of leverage, will vary across sites, we want to study people with mental disorder in a number of different locations.