1. Homework # 2 Civil Commitment versus Outpatient Commitment Instructions: Answer the following question(s): Define and contrast civil commitment and outpatient commitment. What are the criti

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1.       Homework # 2 Civil Commitment versus Outpatient Commitment


Answer the following question(s):

Define and contrast civil commitment and outpatient commitment. What are the criticisms of these laws? Why would they be considered coercive? Why did Virginia change their civil commitment laws and would the change have stopped the Virginia Tech Shooting? Finally, What type of civil commitment is Kendra’s Law, does it have positive results, and why is it criticized?

Your answer should be:

·         1-2 pages

·         Double-spaced

·         Incorporate appropriate course readings and media as your sources of information

·         Properly cite sources using APA.

·         Please submit a PDF or Microsoft Word doc

The book we are using is The Criminalization of Mental Illness: Crisis and Opportunity for the Justice SystemRisdon N. Slate, Jacqueline K. Buffington-Vollum, W. Wesley Johnson.

I have attached some pages from the book to be used for source writing the eassy.

1. Homework # 2 Civil Commitment versus Outpatient Commitment Instructions: Answer the following question(s): Define and contrast civil commitment and outpatient commitment. What are the criti
Homework # 2 Civil Commitment versus Outpatient Commitment  Instructions:  Answer the following question(s): Define and contrast civil commitment and outpatient commitment. What are the criticisms of these laws? Why would they be considered coercive? Why did Virginia change their civil commitment laws and would the change have stopped the Virginia Tech Shooting? Finally, What type of civil commitment is Kendra’s Law, does it have positive results, and why is it criticized? Your answer should be: 1-2 pages Double-spaced Incorporate appropriate course readings and media as your sources of information Properly cite sources using APA. Please submit aa PDF or Microsoft Word doc
1. Homework # 2 Civil Commitment versus Outpatient Commitment Instructions: Answer the following question(s): Define and contrast civil commitment and outpatient commitment. What are the criti
Outpatient Commitment “Of all tyrannies a tyranny sincerely exercised for the good of its victims may be the most oppressive.” — C. S. Lewis1 Outpatient commitment (OC)—otherwise known as “assisted outpatient treatment” or “involuntary outpatient commitment”—is the community treatment version of traditional inpatient civil commitment. Like inpatient civil commitment, outpatient com-mitment is a civil law mandate ordering an individual to obtain treatment against one’s will. Most states even use identical criteria for involuntary outpatient commitment as they do for civil inpatient commitment, at least for certain types of OC (Swartz & Swanson, 2008). Similarly, the profile of a “typical” subject of outpatient commitment is similar to that of inpatient commitment: a young man with schizophrenia, several hospital admissions, a history of noncompliance with community treatment, and often a history of incarceration or other forensic care (Dawson, 2005). The main difference is that with outpatient com-mitment, individuals retain the freedom to continue their “normal” lives in the community (Hiday & Wales, 2013). With the failures of deinstitutionalization, on the one hand, and involuntary hospitalization, on the other, outpatient commitment has been touted as a panacea. Typically, when an individual is not an imminentdanger to him-or herself or to others, outpatient commitment has been more readily accepted. Moreover, it is better received when it is utilized in a limited role with patients who can competently choose between outpatient commitment with involuntary medication or involuntary hospitalization. Ultimately, the goal is that involvement in such a choice would bind them to the treatment should future need arise (Saks, 2003). Outpatient commitment orders may compel an individual with mental illness to submit to any combination of conditions: attending full-day treatment programs; participating in psychotherapy with a therapist, and/or, depending on the state, taking psychotropic medications; undergoing routine urine and blood tests; attending substance abuse groups or self-help meetings; maintaining employment and/or residence in a supervised living facility (Allen & Smith, 2001; Torrey & Zdanowicz, 2001; Wagner, Swartz, Swanson, & Burns, 2003)—or risk sanctions for noncompliance. The ultimate consequence for not following involuntary outpatient commitment strictures is not criminal in nature but is instead a civil sanction—i.e., more intensive community treatment and/or forced hos-pitalization. If an outpatient commitment patient fails to comply with treatment, most statutes allow the presiding clinician to ask the police to bring the non-compliant patient to an outpatient facility, where efforts will be undertaken to encourage the patient to comply with the treatment regimen or be evaluated for inpatient hospitalization (Swartz, Swanson, Kim, & Petrila, 2006 · OUTPATIENT COMMITMENT The use of outpatient commitment has been “fueled by several factors, including limited inpatient resources and brief hospital stays, insufficient community-based resources, a growing homeless persons with mental illness population, highly publicized cases of untreated mentally ill persons, and substance abusers causing havoc or harm” (Anfang & Appelbaum, 2006, p. 212). Depending on the type of outpatient commitment, it is intended, among other things, to prevent relapse, hospital readmission, homelessness, and incarceration (Swartz et al., 2006). Types of Outpatient Commitment Generally in the research literature, three types of outpatient commitment (OC) are discussed. The first is conditional release from the hospital, whereby individuals are prescribed community mental health treatment under threat that they can be returned to hospital care if they are non-compliant with treatment protocols or otherwise deteriorate (Hiday & Wales, 2013). Conditional release is the earliest type of outpatient commitment, having emerged at the beginning of the twentieth century with the primary purpose of reintegrating persons back into society (Cornwell, 2003). Specifically, it is used to “test” a patient’s ability to function in the community while still under supervision before the state has to completely relinquish control. As of 2007, 40 states had conditional release provisions in their statutes (Melton et al., 2007). It appears, of all of these types of outpatient commitment, the conditional release form is used most frequently (Melton et al., 2007). The second type of outpatient commitment is the traditional conception, or “front-end” version, of OC. In this format, outpatient commitment is intended to allow mandated community treatment instead ofinvoluntary hospitalization in the first place, i.e., a less restrictive alternative (LRA) (Wales & Hiday, 2006). Approximately two-thirds of states have this type of outpatient commitment by statute (Melton et al., 2007). “Front-end” outpatient commitment tends to use the same criteria for outpatient commitment as it does for inpatient civil commitment. The final, and most controversial, type of outpatient commitment is what has come to be labeled preventive outpatient commitment. As the name suggests, preventive OC orders community treatment for those who do not yet meet civil commitment criteria, with the purpose of preventing deterioration to the point that civil commitment criteria are met and involuntary hospitalization is needed. It is generally intended for those who are unwilling and/or unable to accept treatment voluntarily, who have a history demonstrating the need for treatment to prevent deterioration that might lead to multiple hospitalizations or dangerousness to self/others, and/or to prevent the revolving door between the mental health and criminal justice systems (Wales & Hiday, 2006). Preventive outpatient commitment can involve forced medication in the community based on a lesser standard than is necessary for involuntary hospitalization (see O’Connor, 2002; Saks, 2003; Schopp, 2003). It is for this reason—e.g., it involves the greatest reach of state authority into an individual’s liberty on the least grounds—that preventive OC has received the most attention, and criticism. As of 2007, ten states had preventive OC statutes2 (Melton et al., 2007); this number is likely higher by 2012 5 · OUTPATIENT COMMITMENT 145 The most well-known and researched of all outpatient commitment laws is New York’s preventive OC statute, colloquially referred to as Kendra’s Law. Kendra’s Law, more formally known as the New York Mental Hygiene Law (2004), defines eligibility for assisted outpatient treatment (AOT) within the following framework (Treatment Advocacy Center, 2008, p. 3 The Current Status of Outpatient Commitment Outpatient commitment has been widely adopted, nationally and even at the inter-national level (Dawson, 2005). Specifically, 44 states and the District of Columbia in the United States have enacted outpatient commitment laws (Treatment Advocacy Center, 2012). However, with the vastly different types of outpatient commitment—e.g., OC as prevention of need for admission to, OC as an alternative to, and OC as conditional release from a hospital—and variation in how these types of OC are im-plemented, it is difficult to compare them (Churchill, Owen, Singh, & Hotopf, 2007; Dawson, 2005). There is also wide variation in how frequently individual states use their outpatient commitment statutes. At the high end, involuntary outpatients represent 25% of all outpatient commitments in a jurisdiction’s community (Hiday & Wales, 2013). At the low end, jurisdictions never use the outpatient mechanism of involuntary treatment, despite having the statute on the books (Hiday & Wales, 2013). Overall, the frequency of use tends to fall toward the lower end.3 Only 8 to 10 states frequently use their laws (Fritz, 2006); among them, only New York actively uses its law (National Stigma Clear-inghouse, 2007).4 Statistically, over half of states with some form of outpatient commitment laws seldom use their outpatient commitment statutes (Appelbaum, 2005; Honig & Stefan, 2005; O’Connor, 2002). In fact, until Virginia Tech, there had been a growing trend of rejecting expansive involuntary outpatient treatment statutes in some states—such as Virginia and New Mexico (U.S. Psychiatric Rehabilitation Association, 2007). The reasons for the infrequent use of outpatient commitment are as vast as the variation in the frequency of its use. According to Wales and Hiday (2006), jurisdictions avoid using outpatient commitment for reasons ranging from liability concerns, to lack of funding (or other resources), to logistical/infrastructure challenges, to attitudes and interests of the key players in the proceedings, to ignorance of and/or skepticism about the law, to mere stagnancy. With regard to liability, concerns about legal issues, coercion, and paperwork deter clinicians and the judges who order outpatient commitment from using the mechanism as an option (Swartz & Swanson, 2008). In particular, since most states use the same criteria for outpatient commitment as they do for inpatient commitment, clinicians are often hesitant to use it. Swartz and Swanson (2008) explain the conundrum: “Labeling a patient as ‘ill enough’ to be confined, then recommending his release to outpatient treatment feels like a liability risk” (Swartz & Swanson, 2008, p. 26). Lack of funding or other resources, coupled with infrastructure and/or logistical challenges, are a dominant reason for the infrequent use of outpatient commitment. Cal-ifornia, for example, passed an outpatient commitment law but then allocated no money and forbade counties from shifting resources from other mental health programs with Civil Commitment “In a free society you have to take some risks. If you lock everybody up, or even if you lock up everybody you think might commit a crime, you’ll be pretty safe, but you won’t be free.” — Former United States Senator Sam Ervin1 “The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness—free them from the Bastille of their psychoses—and restore their dignity, their free will, and the meaningful exercise of their liberties.” — Herschel Hardin2 A young man with treatment for depression and emotional detachment since early childhood becomes a college student. A university professor expresses concerns about the violent content of his writing, and he makes his classmates uncomfortable with his angry detachment, to the point that he is removed from class to receive one-on-one tutoring. Campus police advise him to stay away from several female students who have felt harassed by his “annoying” instant messages, after which he indicates that he “might as well kill [him]self.” Other professors report their concerns, too, about the content of his writ-ing—one depicting the protagonist killing his classmates and then himself—and with his reactions to his grades. One professor goes so far as to offer to attend counseling with him. The student receives treatment but stops going (Virginia Tech Review Panel, 2007). Another young man, despite academic and musical talent, begins to abuse alcohol and smoke marijuana and drops out of high school. Slowly, his “passionate opinions about government” and his “fascination with dreams”—appreciated by friends—become in-creasingly nonsensical and obsessive. He, too, comes to the attention of campus police for repeated disruptions and angry reactions to professors. He withdraws from family and friends and instead rants on the internet—eventually posting an “unsettling video” about his “scam” education, the “need for a new money system, and the government’s mind-manipulation of the masses through language.” He is so disturbing of a presence, tellers at a local bank “feel for the alarm button when he walk[s] in” (Barry, 2011). A third young man, with schizophrenia, in his late twenties, has been hospitalized 13 times. He frequently reports to the emergency room, complaining of hearing relentless voices and describing bizarre—but seemingly innocuous, non-dangerous—delusions that he had lost his neck, his brain had been removed, and he had been inhabited by people (Winerip, 1999). What is the commonality between these cases? If you pay attention to the media, you know that the first two cases describe Seung-Hui Cho and Jared Loughner, two of the mos 112 4 · CIVIL COMMITMENT infamous mass murderers in recent history. You might have thought that this was the com-monality or that the similarity was coming to the attention of university authorities, merely being a male in one’s twenties, and/or slowly unraveling, failing at school and withdrawing from family and friends. However, the third case violates this seeming pattern. There are factors that connect all three of the cases described above. First, each of the individuals described has a mental illness. What’s more, each of them had an untreated mental illness. Third, each of them committed a horrific act of murder. Cho killed 32 people and wounded 17 others, before killing himself, in two separate but related incidents on the campus of Virginia Polytechnic Institute and State University (commonly known as “Virginia Tech”) on April 16, 2007. He had previously been diagnosed with depression, and post-mortem, it has been suspected that he had begun to decline into delusional psychosis. Loughner killed 6 and wounded 13 others at a public meeting with Congresswoman Gabrielle Giffords on January 8, 2011, in Tucson, Arizona. He has since been diagnosed with schizophrenia, yet he has pled guilty to all counts (Spagat & Christie, 2012).3 The last case describes Andrew Goldstein, a man with chronic schizophrenia, who pushed an unsuspecting stranger, Kendra Webdale, from a subway platform into an oncoming train in New York City on January 3, 1999. Sadly, it isn’t until horrific tragedies are committed by people like Cho, Loughner, and Goldstein that the issue of mental illness captures the public’s attention and, hopefully, brings about positive change. Sadly, it is also cases like these that fuel the stigma and fear of people with mental illnesses. Knowing what we know now about the acts they would commit, their behavior leading up to the offenses is haunting. Yet, despite concerns by their treating mental health pro-fessionals, not even these clinicians could have predicted the havoc their clients would wreak. We only have this luxury in hindsight. This leads us to the final commonality between Cho, Loughner, and Goldstein—the similarity least likely to be recognized by the lay public: None of them, despite their behavior leading up to the acts, would have been civilly committed—forced by the state—into treatment in the mental health system. Such is the topic of this chapter and Chapter 5. What Is Civil Commitment? “Involuntary” or “civil commitment” are the terms used when the state intervenes civilly and treats, without one’s consent, individuals with mental illness who require care and/or incapacitation because of self-harming or dangerous tendencies (Melton, Petrila, 3. It is suspected that James Holmes, who allegedly killed 12 people and wounded 58 others in a movie theater in Aurora, Colorado, on July 20, 2012, was also mentally ill. Previously a talented doctoral student in neuroscience, James Holmes’ academic performance began to decline in the spring of 2012 (Leonnig & Achenbach, 2012). He started seeing a university psychiatrist, and by June, she became concerned enough about his potential dangerousness that she called campus police and alerted the university’s threat assessment team (Bazelon, 2012). In the meantime, Holmes failed his oral exams, and he dropped out three days later, before the team had a chance to convene (Harris, 2012). At the time of this writing (January 22, 2013), there is not much more information available; however, that which has been made available suggests he received no further mental health treatment prior to the events of July 20. As with Cho and Loughner, Holmes’ case will certainly hold implications for college and university policies regarding dangerousness and gun control for individuals with mental


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