1. Involuntary Outpatient Commitment Legislation: State Perspectives Virginia House of Delegate's Health, Welfare and Institutions Committee July 30, 2007 Sarah Steverman, MSW Policy Associate National Conference of State Legislatures

2. Common Characteristics of Involuntary Treatment Statutes Most have a “grave disability” provision. Most states permit outpatient commitment. The standards for inpatient and outpatient commitment differ. Some states require outpatient treatment to be shown available before outpatient commitment is granted.

3. Common Characteristics of Involuntary Treatment Statutes continued A person’s history of behavior and treatment can be taken into account when determining whether an individual meets commitment standards. Medication compliance is usually addressed separate from the civil commitment hearing. Outpatient commitment is most often used at the point of discharge from inpatient treatment.

4. Texas Requires a court order for outpatient commitment. Inpatient and outpatient civil commitment uses same processes. Some overlap in inpatient and outpatient criteria. Prior history of up to two years preceding the commitment hearing may be considered.

5. Texas Court may order outpatient treatment if  Person has mental illness that is “severe and persistent.”  Untreated illness will lead to severe distress and the individual will be unable to live safely in the community without mental health services.  The individual is unable to participate voluntarily in treatment as evidenced by past history or current clinical condition making it impossible to make a rational decision to seek outpatient treatment.

6. Michigan Initial detention initiated by psychiatrist or psychologist, peace officer, application of an individual to a court. Availability of community mental health services must be assessed. At least one deposition or testimony by a physician or psychologist must be submitted to the court. Court provides law enforcement with involuntary treatment order.

7. Michigan continued Types of involuntary treatment orders  Hospitalization  Alternative to hospitalization  Combination of hospitalization and alternative treatment Length of time of treatment orders vary. Person with combined order can be returned to the hospital without hearing if deemed clinically appropriate.

8. North Carolina Inpatient and outpatient commitment statutes differ greatly. Outpatient treatment is defined in the statute as a mechanism to avoid inpatient commitment. Prior history may be used to determine civil commitment. Anyone can petition the court to take the person into custody for assessment.

9. North Carolina continued If outpatient commitment is recommended, the court schedules a hearing with the individual and proposed treatment center or physician. Counsel not automatically assigned for IOC Forced medication and treatment not allowed pending hearing. Hearing must be held within 10 days.

10. North Carolina continued Five criteria for outpatient commitment:  Mental illness  Capable of surviving safely in the community with available supervision  Threat of dangerousness (defined in statute) based on history  Mental illness leads to inability to voluntarily seek and participate in treatment  Outpatient treatment is available

11. North Carolina continued Combination of inpatient and outpatient treatment can be ordered. Medication cannot be forced unless immediate danger to self or others. Anecdotal evidence that outpatient commitment is most often used at point of discharge from inpatient treatment.

12. Ohio Treatment of those civilly committed lies with the local boards of alcohol, drug addiction, and mental health services, including financial responsibility. Provides incentives for local boards to limit commitment and increase community services. Court can order person into a variety of settings, but the treatment provider designated to provide care must consent. Commitment is usually to the local board, who then makes decision.

13. Ohio continued Medication compliance is separate issue from civil commitment and requires a judicial hearing. 2000 Ohio Supreme Court Decision: Steele v. Hamilton County Community Board

14. Oregon Court and Mental Health Division Director work closely together during civil commitment procedures. With the approval of the court, Mental Health Division Director can commit individual to outpatient treatment only if the treatment is available. Director establishes terms of outpatient commitment. Outpatient commitment can be revoked or modified by Director when “it is in the best interest of the person.”

15. Oregon continued Outpatient commitment used rarely in Oregon, trial visits from hospital used more frequently. Anecdotal evidence that lack of community resources may place individuals at greater risk for commitment. Inconsistencies between rural and urban application of the statute.

16. Wisconsin Permits the use of medical records data in making commitment determination. Specifies what does not constitute adequate proof that the individual meets commitment criteria.  If protection/treatment exists in the community and the person is likely to take advantage of those services. Provides for a “settlement agreement” postponing commitment hearing for up to 90 days while person participates in outpatient treatment. 5 th Standard-question of capacity and prospect of deterioration in the absence of treatment.

17. Wisconsin Enrollment in a health plan determination before assessment or treatment under civil commitment. Court may appoint a temporary guardian for up to 30 days.

18. Policy Issues The statute is only one element of the treatment issue. IOC is only successful if there are adequate community resources. Outpatient commitment relies on good communication between the court, assessing psychiatrist or psychologist, treatment provider, and often the mental health authority. IOC is often administered inconsistently, especially between rural and urban areas. Availability of evidence-based treatment prevents the need for IOC.

19. Sarah Steverman Phone: 202-624-3583 Email: sarah.steverman@ncsl.org sarah.steverman@ncsl.org Resources: M. Susan Ridgely, John Borum, John Petrila “The Effectiveness of Involuntary Outpatient Treatment: Empirical Evidence and the Experience of Eight States” http://www.rand.org/pubs/monograph_reports/MR1340/ http://www.rand.org/pubs/monograph_reports/MR1340/ NCSL Mental Health Webpage http://www.ncsl.org/programs/health/mental.htm