Confusion About Outpatient Commitment

In Reply: Mr. Heyrman argues that two "errors" obfuscate the discourse about involuntary outpatient commitment: that there is a lack of consensus about the legislative intent(s) behind outpatient commitment and that there is a lack of understanding of the legal criteria for outpatient commitment, especially regarding dangerousness and imminent risk. Although we agree that both points highlight long-standing dilemmas in commitment law, it is not clear to whom these errors should be attributed.

Both of these points have been long and heatedly discussed in the literature on involuntary commitment, and we refer interested readers to excellent discussions of shifting legislative intent, legal standards for involuntary commitment, and interpretations of dangerousness and imminent risk (1,2,3,4).

Mr. Heyrman is quite right that the legislative intent embodied in these statutes and their judicial interpretation vary widely across and even within states. Most thoughtful commentators acknowledge this variability and point out the difficulty in generalizing from one jurisdiction to another. It is also quite true that the operationalization of statutory criteria introduces additional variability. Statutes rarely operationalize legal criteria in a manner that clinicians can readily adopt, and insufficient attention has been given to developing operational criteria for the use of legal criteria in clinical practice. Variance in statutory criteria and lack of clear operationalization of criteria leave ample room for variations in the legal and clinical practice of inpatient and outpatient commitment.

Several organizations, such as the National Center for State Courts and the American Psychiatric Association, have proposed model commitment statutes, guidelines, and resource documents to help states that want to recodify commitment statutes and procedures (3,4,5). Adapting these model statutes and recommendations would be a clear step in the right direction. An additional approach is to try to improve the practice of outpatient commitment by carefully evaluating the existing research base on outpatient commitment and using it to develop practice guidelines that can be operationalized.

The intent of the special section in the March issue of Psychiatric Services was to identify some of the key flash points in the controversy about outpatient commitment. Mr. Heyrman has pointed to additional areas also worthy of discussion.