Mandated community treatment: applying leverage to achieve adherence.

Treating people with mental disorder without their consent always has been the defining human rights issue in mental health law. For centuries, unwanted treatment took place in a closed institution, a mental hospital. What has changed is that in recent years the locus of involuntary treatment has shifted from the closed institution to the open community. Much of the strident policy debate on outpatient commitment, a civil court order requiring a person to adhere to mental health treatment in the community, treats it as if it were simply an extension of inpatient commitment, viewing it within the same conceptual and legal framework historically used to analyze commitment to a mental hospital. Increasingly, however, it is becoming apparent that concepts developed within a closed institutional context do not translate well to the much more open-textured context of the community. It is for good reason that mental hospitals have been described as total institutions: a single source supplies an individual’s lodging, delivers benefits, maintains order, and provides treatment. In the community, however, one source supplies an individual’s lodging (a housing agency), another delivers benefits (a welfare agency), a third maintains order (the criminal justice system), and a fourth provides treatment (the mental health system). Outpatient commitment is better seen as only one of a growing array of legal tools from the social welfare and judicial systems now being used as leverage to ensure treatment adherence in the community.