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Letter   |    
Jo C. Phelan; Dorothy M. Castille; Bruce G. Link
Psychiatric Services 2010; doi:
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In Reply: Dr. Geller wants to know whether "coercion is effective in some cases of outpatient treatment." He is disappointed that our article did not answer the question that he assumes to be the only reason for conducting a study such as ours. Dr. Geller's question is interesting but by no means the only question of importance in evaluating outpatient commitment under Kendra's Law. We begin by indicating why we cannot answer the question Dr. Geller poses and then discuss the value of what we did learn.

As discussed in our article, one of the constraints on researchers who study outpatient commitment is that such research must be conducted within existing systems of treatment and criminal justice. Kendra's Law mandates both court-ordered treatment and enhanced services for individuals assigned to assisted outpatient treatment. The legislation stipulates that the interventions be delivered as a combined package. Our opportunity as researchers was to study the effects of this "package deal" by comparing individuals assigned to assisted outpatient treatment with those who were not.

At the outset of our study there was substantial disagreement about the utility of outpatient commitment under Kendra's Law as it was implemented, with the full combination of legal coercion and enhanced services. Some people predicted that the policy would be harmful, whereas others were convinced that it was beneficial. Therefore, it is important to point out that our results could have been dramatically different, such that Dr. Geller would have had to critique us instead for being unable to know whether coercion is harmful in some cases of outpatient commitment. We learned something important about a real-world policy.

Specifically, we learned that outpatient commitment, as enacted under Kendra's Law, was associated with less violence perpetration and suicide risk and improved illness-related social functioning. Equally important, we learned that outpatient commitment was not associated with perceived stigma or coercion among those receiving the intervention. These are things we did not know before the study was conducted, and they were not the answers that many would have predicted. Our study of Kendra's Law was largely motivated by career-long concerns over the problem of stigma associated with mental illness. We were surprised that individuals assigned to assisted outpatient treatment did not report more stigma or coercion.

Dr. Geller is correct that our results neither "justify an expansion of coercion in psychiatric treatment," as we stated, nor "refute the expansion of coercion either," as he stated. However, because our results generally reflected favorably on the effects of outpatient commitment, we felt that unwarranted expansion of coercion was a more likely consequence of our publication than unwarranted constriction of coercion. This is why we chose to emphasize the former in our conclusion.

No study can answer all questions. We recognize the value of disentangling the combined package of legal coercion and enhanced services. But this in no way undermines the importance of studying the success or failure of real-world policies as implemented in real-life settings with consequences for real people.




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