Forced Treatment Doesn't
The promise of community mental health service was neither funded nor fulfilled.
By Vicki Fox Wieselthier and Michael Allen
In the wake of a handful of highly publicized violent incidents involving people with mental illness, advocates of forced treatment have suggested that court-ordered "outpatient commitment" will make our communities safer. One example is the piece by E. Fuller Torrey and Mary T. Zdanowicz ["Deinstitutionalization Hasn't Worked," op-ed, July 9]. The problem is that outpatient commitment doesn't work. Worse yet, the threat of forced treatment drives people away from the supports they need while stealing the resources necessary to support voluntary services with proven effects.
Outpatient commitment is being touted as a quick fix that will make law-abiding citizens safe on the streets. Its proponents would oppress an entire class of citizens on the basis of misguided fear. While doing very little to improve public safety, outpatient commitment would force people with certain psychiatric diagnoses to take powerful medications and comply with treatment orders as a condition of living in the community. Noncompliance would be punished by readmission to an inpatient psychiatric facility.
Forced treatment advocates make a series of false claims. The first exaggerates both the dangerousness of people with mental illnesses and the effectiveness of outpatient commitment. Study after study has found that most people with serious mental illnesses are no more dangerous than the general population. In May 1998 Dr. Bruce Link commented in the Archives of General Psychiatry: "To date, nearly every modern study indicates that public fears are way out of proportion to the empirical reality. The magnitude of the violence risk associated with mental illness is comparable to that associated with age, educational attainment, and gender."
Research also shows that coercive measures provide no benefit to people with mental illness. The only controlled study released to date concludes that individuals provided voluntary, enhanced community services did just as well as those under commitment orders who had access to the same services.
It's a very different situation from, for example, that which occurs when a person is court-ordered to receive treatment for tuberculosis. In the case of TB, there is no doubt about the validity of the diagnosis, the effectiveness of the treatment and the public health risk of active TB.
Pro-force advocates also claim that nearly half of those individuals with schizophrenia or manic depression lack the insight necessary to recognize their need for treatment. The truth behind the headlines is that many of those recently involved in acts of violence had been begging for mental health services only to be told that the services they were requesting could not be provided. The dollars to pay for them were not there.
Court orders will do little to increase the availability of services where they do not exist. What court-ordered treatment will do is reallocate what few dollars are in the system so that one will have to be caught in the outpatient commitment net to get any treatment at all. When the system is required to make services available to people for whom a court has ordered treatment, it simultaneously must deprive others of effective, voluntary services. Every dollar that is spent on force is a dollar that is not available to pay for services that really work -- peer support, outreach, adequate housing, jobs programs and rehabilitation.
Finally, mental health professionals themselves admit that there is no reliable assessment tool to determine who might belong to that small group of individuals who might actually be violent. According to the American Psychiatric Association, "Psychiatrists have no special knowledge or ability with which to predict dangerous behavior. Studies have shown that even with patients in which there is a history of violent acts, predictions of future violence will be wrong for two out of every three patients." Far from being a safety net, outpatient commitment will operate as a dragnet, pulling in and confining people who pose no risk to themselves or others.
The promise of deinstitutionalization -- that money would be reinvested in community mental health care -- was never fulfilled. Civil rights and mental health consumer advocates are at the forefront of the campaign for adequate funding. If pro-force advocates redirected their multimillion-dollar budgets and joined this campaign, we finally could make good on the promise and improve the quality -- and safety -- of all of our lives.