You asked what other states do about committing people with psychiatric disabilities to outpatient treatment, a practice known as involuntary outpatient civil commitment or assisted outpatient treatment.

SUMMARY

Every state allows a family member, guardian, or the state to ask a court to commit to a hospital people with mental illness who are a danger either to themselves or others. Courts in 41 states plus the District of Columbia can also commit such people to outpatient treatment. Treatment may include taking prescribed medication; participating in group or individual therapy, training, or educational or vocational programs; residing in a supervised living arrangement; and reporting to a case manager.

Of the 41 states with outpatient commitment laws, 23 rarely use them, according to a 1995 national survey on the use of outpatient commitment. Connecticut is among the nine states that do not have such a law. The others are California, Florida, Kentucky, Maine, Maryland, Nevada, New Jersey, and New Mexico.

The two most common forms of outpatient involuntary treatment are (1) initial commitment where a person is committed directly to outpatient treatment, without having first been committed on an inpatient basis, and (2) conditional release where outpatient treatment follows a period of inpatient treatment. An initial outpatient commitment may be an alternative to inpatient commitment or it might be prescribed treatment for people whose conditions do not warrant hospitalization.

Courts use two standards for determining whether to commit someone to outpatient treatment. The “dangerousness standard” requires the person's behavior, either actions or threats, to show him to be likely to seriously harm himself or others. The U.S. Supreme Court has found this standard to be constitutional. The other standard is called “need for treatment.” Here, the patient's current condition and clinical history must show that he needs treatment to prevent cognitive deterioration or disability that would lead to dangerousness. The Supreme Court has not ruled on this standard's constitutionality.

Outpatient commitment emerged in response to the need for continued treatment in the face of stricter inpatient commitment laws, the perceived need for alternatives to institutionalization, and as a fix to "revolving door" problems created when patients released from inpatient treatment stopped taking their medication. New York's adoption of “Kendra's Law” in 1999 in response to a mentally ill person pushing a woman in front of an oncoming subway train renewed debate over the issue. Since then, three states, New York, Wyoming, and Montana, adopted involuntary outpatient commitment laws and 11 others amended existing laws, typically to make such commitment easier.

Connecticut's approach to this population, which the General Assembly authorized in PA 00-216, is the use of “peer engagement specialists,” people recovering from psychiatric disabilities who are specially trained to work in a multidisciplinary team with potentially dangerous people who have a history of rejecting traditional treatment. The program began operating in four local mental health agencies in June 2001.
 

STATES WITH INVOLUNTARY OUTPATIENT COMMITMENT LAWS

The vast majority of states have some form of involuntary outpatient commitment statute. But most rarely use it, according to an issue brief on Outpatient Civil Commitment prepared by Tracy Delaney at the National Conference of State Legislature's Health Policy Tracking Service.

Table 1 shows the states that allow involuntary outpatient commitment, the form of commitment (initial or conditional), and how frequently they use it. (The information on frequency of use comes from Torrey and Kaplan, “A National Survey of the Use of Outpatient Commitment,” Psychiatric Services, v. 6 no. 8 (August 1995), p.778.) We have attached a copy of Delaney's issue brief, which briefly summarizes the law in each of these states.

Table 1: States With Outpatient Commitment Laws 

Source: NCSL

RECENT TRENDS

States Newly Adopting Outpatient Commitment

New York, Wyoming, and Montana are the most recent states to adopt outpatient civil commitment laws, the first two in 1999, the latter this year. New York adopted the treatment standard for determining commitment. A person must have a recent history of refusal to comply with treatment that resulted in multiple hospitalizations or have a history of violence. Wyoming adopted a modified dangerousness standard. In addition to demonstrating a substantial probability that he might physically harm himself or others, the law defines dangerousness to include behavior that shows a person's mental illness makes him so unable to care for himself that his condition is likely to deteriorate to the point of physical harm. It also covers potential destabilization due to failure or refusal to take psychotropic medication.

Wyoming also allowed people to make mental health advance directives. This is an emerging concept, according to NCSL's Delaney, that works like a living will. It allows people with mental illness to express how they wish to be treated when they are not competent to make treatment decisions. It authorizes a professional to act or a court to use it in a legal proceeding.

Montana's new law allows a court, following the existing procedure for inpatient commitment, to commit a person to assisted outpatient treatment in a community facility or program or order a course of treatment. The court's options include requiring a person to follow a specific treatment plan or live in a specific type of arrangement. It can order outpatient treatment if it finds that (1) the person has harmed, or imminently threatens to harm, himself or others; (2) is substantially unable to care for his basic needs; or (3), if left untreated, his mental disorder will deteriorate to the point where he will become dangerous or unable to care for himself. The court must find one of these conditions exists beyond a reasonable doubt or by clear and convincing evidence, depending on the condition.

States Modifying Existing Outpatient Commitment Laws

South Dakota, West Virginia, Kansas, and Washington have modified their definitions of dangerousness in ways that seem to make it easier to apply their existing outpatient commitment laws. South Dakota set a reasonableness standard (the lowest of the three standards of proof) for showing that a person is dangerous. West Virginia and Kansas changed their definitions of “likely to cause serious harm” to include behavior that shows a substantial likelihood that a person's inability to care for himself will lead to death, injury, physical or mental debilitation or life-threatening disease. And Washington required a court determining whether an inpatient or less restrictive alternative is needed to give great weight to whether the person's prior history shows repeated hospitalizations or a pattern of offenses and convictions.

A new Iowa law provides a different twist on conditional commitment. Generally, conditional commitment applies to a person being discharged from an inpatient commitment. Iowa now permits a court to include in its outpatient treatment order a provision that, if the person fails or refuses to submit to treatment, he can, after notice and hearing, be committed to inpatient treatment.

CONNECTICUT'S APPROACH

Connecticut does not permit involuntary outpatient commitment. Instead, the legislature has authorized the Department of Mental Health and Addiction Services (DMHAS) to use “peer engagement specialists” (PA 00-216). These specialists are themselves people recovering from psychiatric disabilities. They are specially trained to work with individuals who the DMHAS commissioner determines (1) have or threaten to injure themselves or others, (2) have persistently rejected traditional services, and (3) need and would benefit from an engagement specialist's services. Working as part of a multidisciplinary team, the specialists assess people; help develop recovery plans; consult with care agencies and assist care managers; provide outreach, support, and follow-up services; serve as role models; teach life and interpersonal skills; and help develop community support systems.

The program began operating with eight specialists in four local mental health agencies on June 15, 2001. The agencies are: Community Mental Health Center, Waterbury Mental Health Authority, Southeastern Mental Health Authority, and Valley Mental Health Center.

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