Showing papers by "John Monahan published in 2001"

Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence

Abstract: Rethinking Risk Assessment tells the story of a pioneering investigation that challenges preconceptions about the frequency and nature of violence among persons with mental disorders, and suggests an innovative approach to predicting its occurrence.

Mandated community treatment: Beyond outpatient commitment

Abstract: Outpatient commitment, although often viewed as merely an extension of inpatient commitment, is only one of a growing array of legal tools used to mandate treatment adherence. The authors describe various forms of mandated community treatment. People with severe and chronic mental disorders often depend on goods and services provided by the social welfare system. Benefits disbursed by representative payees and the provision of subsidized housing have both been used as leverage to ensure treatment adherence. Many discharged patients are arrested for criminal offenses. Favorable disposition of their cases by a mental health court may be tied to participation in treatment. Under outpatient commitment statutes, judges can order committed patients to comply with prescribed treatment. Patients may attempt to maximize their control over treatment in the event of later deterioration by executing an advance directive. The ideological posturing that currently characterizes the field must be replaced by an evidence-based approach.

Special Section on Involuntary Outpatient Commitment: Introduction

Abstract: PSYCHIATRIC SERVICES © March 2001 Vol. 52 No. 3 323 In almost every community in the United States, there is a troubling population of severely mentally ill individuals who are ineffectively served by resource-poor community mental health programs. These individuals fre quently relapse and are rehospitalized (1–3), in many cases because their treatment is complicated by nonadherence. They frequently, and often unsuccessfully, interact with many other services and agencies—substance abuse treatment programs, civil and criminal courts, police, jails and prisons, emergency medical facilities, social welfare agencies, and public housing authorities (4–7). Some, while visibly ill, never seek or are engaged in any form of treatment. Public concern about the quality of community-based treatment is unfortunately focused on rare but highly publicized violent acts committed by these hard-to-serve individuals (8). The pressing need to improve community treatment outcomes has led policy makers and clinicians to focus on legal mechanisms to improve treatment adherence, including court-ordered treatment in the community, often called involuntary outpatient commitment (9). Many states have embraced outpatient commitment as a remedy for the most visible failures of community treatment. Outpatient commitment is permitted in virtually all states (10–13); however, its use varies considerably among and within states for a variety of reasons, including poor specification and understanding of commitment criteria, weak mechanisms of enforcement and liability, and other concerns of providers (4,10,14–16). Use of outpatient commitment may also be limited because many consumers, mental health law advocates, and clinicians oppose any form of coercion in treatment, arguing that it infringes on civil liberties, extends social control into the community, and alienates mentally ill persons from seeking treatment (17–20). Proposed as a less restrictive alternative to involuntary inpatient commitment, outpatient commitment has amassed a host of supporters and critics, despite a relative paucity of empirical evidence about its risks or benefits. Proponents of outpatient commitment assert that it works not only by exerting pressure on individuals with mental illness and their families, which motivates adherence to treatment under threat of coercion and greater confinement, but also by putting pressure on the mental health service system and mobilizing supportive services, outreach, and clinical surveillance. This mobilization in turn improves timely access to scarce treatment resources for persons most in need. In the view of those who advocate for it, outpatient commitment provides greater autonomy than would otherwise be expected for mentally ill individuals at risk of relapse and recidivism. Furthermore, if outpatient commitment effectively reduces hospital recidivism, it should conserve resources for reinvestment to extend and improve community-based services (9,10). Nonetheless, as the papers in this special section illustrate, the intensity of the debate about outpatient commitment is considerable. A recent report from the subcommittee on mandatory outpatient treatment of the American Psychiatric Association’s council on psychiatry and law concluded that outpatient commitment could be a “useful tool in an overall program of intensive outpatient services aiming to improve compliance, reduce rehospitalization rates, and decrease violent behavior among a subset of the severely and chronically mentally ill” (21). The subcommittee recommended that outpatient commitment orders be available for preventive use only for patients with a well-documented history of relapse, deterioration, or dangerousness. It also recommended that the orders be available for patients who, as a result of their mental illness, are unlikely to comply with needed treatment. According to the subcommittee, such orders should be used only when adequate resources are available to provide effective treatment, and they should include statutory authority for initial commitment periods of 180 days with extensions as ordered. The subcommittee recommended that patients on outpatient commitment receive a thorough medical examination. It pointed out that clinicians providing the mandated treatment should be involved in the decision-making process to ensure that the proposed treatment is available. Patients’ treatment preferences should be assessed, and patients should be informed of expectations about compliance. Finally, the subcommittee recommended that procedures to be followed in the event of a patient’s noncompliance should be specified. The subcommittee’s resource document does not make a recommendaSpecial Section on Involuntary Outpatient Commitment: Introduction

Legal Process and Social Science: United States

Abstract: The use of social science in American courts is rooted in the legal realist movement of the early twentieth century. However, the standard for the admissibility of scientific evidence was not established until the Supreme Court's decision in Daubert v. Merrell Dow Pharmaceuticals in 1993. Social science evidence has three uses in court: to assist judges in making general law, to assist juries in determining specific facts, and to provide juries with general context for determining specific facts. At the beginning of the twenty-first century, efforts to educate judges in social science methods are burgeoning.