Barriers and Challenges to Successful Implementation of Involuntary Outpatient Commitment

Background and Purpose: Involuntary Outpatient Commitment (IOC), also referred to as Assisted Outpatient Treatment, is a controversial feature of mental health law nationwide.  Outcome studies using randomized designs indicate mixed support for the effectiveness of IOC in preventing recidivism and improving quality of life outcomes; one possible reason may be significant variability in the implementation of IOC interventions.  This presentation, derived from a mixed methods study of a newly implemented IOC law, explores challenges and barriers to effective implementation from the perspective of providers and administrators.

Method: Six initially funded programs (three urban; three rural or suburban) under a new state law for IOC were studied during their first three years of implementation. Abstraction of program records was used to gather information on number of clients served (n=789), client demographic and clinical characteristics, and outcomes. Qualitative interviews with program staff (n=31) were used to gather information on program implementation.  Interviews were transcribed and coded using atlas.ti, and theoretical memos and mapping diagrams were used to integrate core concepts and themes into an integrated framework.

Findings: IOC contracts were awarded to six agencies to link clients to treatment programs, monitor service use, and interface between clients and civil courts.  Across the 789 individuals served, average commitment length was 200 days, although a sizeable proportion (32%) did not receive a full 90 days of treatment prior to being hospitalized or discharged for other reasons. Early recruitment of consumers was slowed by lack of information and trust from collaborating agencies in the mental health system responsible for referrals and processing of commitments, such as psychiatric emergency rooms, court counsel, judges, and community providers. A second set of barriers stemmed from variation in the availability and accessibility of services to which newly admitted consumers could be linked, with some rural programs, as a result, engaging in direct service delivery in addition to case management, increasing the cost of services. Across all programs, perceived inability to enforce commitments in cases of treatment noncompliance mounted a persistent barrier to effective implementation, resulting in the need to modify admission criteria to exclude consumers who refused services outright and focusing efforts on relational engagement as a way of motivating clients to adhere. 

Conclusions and Implications:  Public debate regarding involuntary outpatient treatment presumes that the mere presence of a treatment mandate will address treatment noncompliance by making treatment compulsory for clients.  In-depth study of programs, however, suggests that implementing IOC orders involves the need for tight interagency coordination and breaks down if services are not readily accessible or available.  Even when linked to services, clients who fail to fulfil court ordered expectations cannot easily be mandated to attend, making the need for effective and skilled engagement an ongoing necessity for professionals operating in publicly funded mental health systems.