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Taking Issue   |    
Conditional Hospital Release: Conveying the Wrong Message?
Robert Bernstein, Ph.D.
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.11.1553
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The three articles in this issue by Segal and Burgess offer strong arguments that conditional release from psychiatric hospitalization holds important benefits for people with serious mental illness. Drawing on a large ten-year database, these Australian studies demonstrate widespread reliance on conditional release, associated with outcomes such as reduced inpatient days and lower mortality rates. Yet this research leaves many important details blurred. The data do not establish causal links, and the outcomes included are at best blunt indicators of clinical effectiveness. Also unclear is how court-endorsed postdischarge monitoring—a rather indirect intervention as things go in public mental health—can prod better outcomes for consumers who are ostensibly among the hardest to serve.

What is clear from the data is the mental health system's blithe engagement of the courts in postdischarge planning, a notably perplexing scenario for the many individuals who entered the hospital voluntarily only to find court-mandated oversight after "successful" inpatient care. Also revealing is the pervasive sense of powerlessness among consumers in challenging such arrangements. In reality, many consumers know that hospital discharge is always conditional; involuntary readmission looms whenever civil commitment criteria are met.

Still, conditional release is more than mere ritual. Although the authors frame this intervention as a vehicle for earlier hospital release, thus furthering the system's "least restrictive" ambitions, myriad factors that erode basic rights are also at play: court action misdirected at the victims of neglect rather than at neglectful public systems, a coercive tradition that undermines personal responsibility and recovery, and cynicism about the true potentials of both good clinical interventions and individuals with mental disabilities.

Research suggests that good community services may be the actual key to success after discharge. However, conditional release can be viewed as an official affirmation of skepticism about an individual's prospects in the community service system. By relying on this legal tactic, mental health professionals turn to the courts for what should be regarded as a sentinel clinical problem: a substantial number of people with the serious mental illnesses common in the public mental health system are at extreme risk of relapse. In obtaining court orders to push engagement with the existing service array, the system tacitly endorses as adequate the 15-minute outpatient "therapy" sessions often available to these individuals and suggests that limited professional know-how offers no recourse but the legal system. Beyond being inconsistent with the science, this sense of hopelessness, unthinkingly expressed in routine court documents, sends a disparaging message to mental health consumers and to society.




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