$3.9 Million Grant Extends Research on Community-Based Treatment of Mental Disorders

Law professor John Monahan, director of the Research Network on Mandated Community Treatment, said "outpatient commitment" should be seen as only one of a growing array of legal tools to ensure that patients with mental disorders get treatment.

A program designed to get greater compliance from mentally ill patients whom the courts instruct to get community-based treatment for their conditions has received an additional $1.3 million per year for the next three years from the John D. and Catherine T. MacArthur Foundation. Phase II plans of the Research Network on Mandated Community Treatment will measure which forms of leverage over patients best gets their cooperation in maintaining their treatment plans, according to network director John Monahan, a psychologist and professor at the Law School.

"Mandated mental health treatment is the single most contested human rights issue in mental health law and policy today," Monahan said. Forty states have laws authorizing outpatient treatment for patients with mental disorders but the public was essentially unaware of them until New York passed "Kendra's Law" after a woman was fatally pushed under a subway train by a man with a history of untreated mental illness, he said. California's version of this statute, called "Laura's Law" after a victim in that state, went into effect on January 1, 2003.

Leverage over patients includes Social Security benefits and subsidized housing controlled by social service agencies, the terms of probation for those with criminal records and the prospect of leniency from mental health courts. Additionally, 15 states have enacted laws that allow patients to make psychiatric advance directives that describe the treatment they want should they later find themselves incapable of making such decisions.

Mandated treatment is becoming increasingly common. In North Carolina one-third of those discharged from psychiatric hospitals are placed on outpatient treatments and in New York more than 2,500 people a year are evaluated for "outpatient commitment," according to Monahan. Between 300,000 and 450,000 criminal defendants with serious mental disorders are given probation every year and the number of states with mental health courts has grown to 33 from just one in 1997, he said. The goal of the network is to conduct empirical studies of how successfully the shift to outpatient treatments is working.

"It is not unusual for those with mental disorders to resist treatment. In the past patients were confined and treated in mental hospitals. Now they are out in the community. It's becoming apparent that the legal framework used in a closed institutional context is not translating as well to less structured, open environments," Monahan said.

In 1979 the U.S. Supreme Court, in the case of Addington v. Texas, raised the standard of proof necessary for states to invoke inpatient treatment from a "preponderance of the evidence" to "clear and convincing evidence," stressing an individual's interest in not being involuntarily confined. "Civil commitment constitutes significant deprivation of liberty that requires due process protection," the court said.

"This has raised the question of whether states must meet the same standard for mandated outpatient treatments as they must for inpatient treatment, since no one is being 'confined' or deprived of their liberty in the community," Monahan said. "Currently used concepts are not answering this question. Rather than viewing outpatient commitments as a simple extension of commitment to a mental hospital we believe that outpatient commitment should be seen as only one of a growing array of legal tools now being used to ensure treatment adherence in the community.

The network, whose twelve members also include Law School professor Richard Bonnie, will be examining avoidance of loss of money, loss of housing, jail or hospitalization as leverage. Information is also needed on the prevalence of mandated community programs, how they are being implemented and how the results are being measured.

"The legal status of many forms of mandated treatment is currently uncertain," Monahan said. "As courts begin to address these issues, empirical research will play a decisive role in judicial deliberations. Furthermore, there are ethical questions. For example, patients may see the money they receive as theirs to decide how to spend, whereas others could see it as taxpayers' money to be used as the government chooses to."

The MacArthur Foundation funded Phase I of the Network in 2001. Monahan said results of current research will be reported by 2005.