Outpatient Voluntary Treatment As Alternatives To Ioc example essay topic

Part One In 1955, over 559,000 individuals resided in inpatient psychiatric hospitals. By 1995, however, the number had drastically diminished to 69,000, (National Health Policy Forum, 2000). This drastic reduction was largely due to the discovery of antipsychotic medications in the 1950's, and the deinstitutionalization movement of the 1960's, wherein several thousands of mentally ill individuals were released from psychiatric institutions to return to their communities for treatment. Mental health centers (MHCs) were conceptualized during deinstitutionalization to provide treatment to these newly-released mentally ill persons in their communities. Although efforts were well-intended, the MHCs failed to serve the neediest subset of individuals. Instead, they served those who had minor psychiatric diagnoses and needed little treatment.

As a result, the United States experienced an increase in the number of homeless individuals, most of whom still exhibited psychotic symptoms. Involuntary Outpatient Commitment (IOC) was created to serve those "forgotten" mentally ill individuals without placing them back in institutions. Ideally, IOC will increase community tenure for the severely mentally ill, decrease the likelihood of decompensation, and provide the necessary treatment by means less restrictive than hospitalization, (Boru m et al., 1999). IOC is a civil procedure whereby a judge orders a person with a mental illness to comply with outpatient treatment within the community, or risk sanctions such as being forcibly brought to treatment by law enforcement officials, (Swartz et al., 2003). The legal authority in IOC is the state's parents patria e power, which provides for the protection of disabled individuals, and its police power, which involves the protection of others. IOC is commonly used for persons with schizophrenia, bipolar disorder, or other psychoses, especially if there is a history of medication non-compliance or repeated inpatient psychiatric admissions, (Torrey & Kaplan, 1995).

The national Department of Mental Health receives a certain amount of money each year from the federal government. From this, state mental health departments draw a significant amount of their funds. It is through the state mental health departments that IOC is largely funded. Although IOC is delivered at the local level, those municipalities receive funds from their state mental health department. IOC was created largely through mandates provided by the Olmstead Act (1999). The Olmstead Act requires public agencies to provide services "in the most integrated setting appropriate to the needs of qualified individuals with disabilities".

Further, the act mandates that states place qualified individuals with mental illnesses in community settings, rather than in institutions. Being placed under IOC is contingent upon whether or not such placement is appropriate, affected persons do not oppose such placement, and the state can reasonably accommodate the placement, taking into account resources available to the state and needs of others with disabilities, (The Center for an Accessible Society, 1999). In conclusion, the Olmstead Act provided for the legal groundwork to both provide and enforce IOC. Research has shown IOC to be more effective when combined with additional components. Examples of these components include psychiatric advance directives, Assertive Case Management (ACM), representative payees, conditional release, conservatorship / guardianship, and mental health courts. Psychiatric advance directives are legal documents that permit mentally ill individuals to authorize and specify treatment in anticipation of future periods of mental incapacity.

ACM consists of mental health teams that actively assist with treatment in the home. Representative payees are trusted persons designated by a mentally ill individual that help that individual use funds wisely by being the payee of benefits. Conditional release is when clients are released on conditions that they follow their treatment plan, including taking medications. Conservatorship / guardianship is when a court appoints an individual to make decisions for a legally incompetent individual. Mental health courts offer the mentally ill an alternative to incarceration through supervised treatment, (Torrey, Zdanowicz, Bentley, & Taylor, 2003). While use of all of these components is not necessary or even recommended, utilizing some of them has been shown to increase compliance with treatment.

The process by which IOC is recommended for a client is quite stringent, as it is important to ensure that only the neediest individuals get remanded to IOC. Several criteria must be met before one gets remanded to IOC. These criteria include being age 18 or over, being considered by clinician to be unlikely to survive safely in the community, having a history of treatment refusal that is considered to have contributed to two or more recent hospitalizations or a history of one or more threats or acts of violence to self or to others, and being found unlikely to voluntarily accept, but likely to benefit, from services. The IOC process begins with the client being the subject of a petition to the court requesting IOC. A number of parties may petition the court for a given individual's outpatient commitment.

These parties include directors of public service organizations, parole or probation officers, adult family members, and adult roommates. The petition, along with an affidavit from a physician, is presented to the supreme or county court in the individual's home county. As the law provides, the court then schedules a hearing within three days of receipt of the petition. The court also must notify the subject of the petition of the hearing date and time, but may hold the hearing even if the subject is not present.

The individual is entitled to free legal counsel or other counsel at his / her own expense. If he / she has refused to be examined by the physician providing the affidavit, the court may order that the individual be taken into custody and transported to the hospital for this examination. Once the court finds the subject of the petition eligible, it approves a treatment plan. This plan, submitted by the physician, must include case management and may include any of the following: medication and testing to confirm compliance; individual and / or group therapy; day programming; educational and / or vocational training; treatment and counseling for alcohol or other substance abuse and testing to confirm sobriety; supervised living and any other services that are intended to treat the petitioned's psychiatric disability. The initial commitment is in place for six months, and may be reviewed annually after that point. In the event that an individual with an active commitment chooses not to follow his / her treatment plan in part or in whole, a physician may order an involuntary hospitalization.

This hospitalization may not exceed 72 hours unless the individual is found to meet the traditional dangerousness criterion for involuntary care, (Carpenter, 2001). In order for IOC to be effective in rehabilitating its consumers, a few basic needs must be satisfied. One, for example, is the need to be adequately financially supported. Without adequate resources, IOC will be unable to sufficiently serve clients.

Adequate resources include having materials to educate clients on dual diagnosis, mental illness, recovery, etc., having ample staff to ensure treatment is effective, having facilities that are suitable to offer day programs, etc. Without these crucial resources, IOC will be unsuccessful in rehabilitating its consumers. Another need that must be met is that continuity of care must be ensured. In other words, both before and after IOC, all systems involved need to take a proactive approach at ensuring that clients follow their treatment plan.

The treatment team must ensure that each client proceeds with all elements of the treatment plan as though they are still court-ordered to do so. A final need that must be met is that the treatment staff must be genuine in its efforts to rehabilitate clients. Research has shown that if the treatment staff does not take a client's rehabilitation seriously, the likelihood that the client will relapse upon release from the court order significantly increases, (Monahan et al., 2001). Courts should act as a quasi-administrator to these programs, ensuring that the treatment staff is providing acceptable treatment.

IOC is built upon the value premises that mentally ill individuals need help, that it is society's responsibility to take care of these individuals, and to provide treatment in the least restrictive setting possible to ensure that each client is not inappropriately placed in the wrong setting. Although some goals of IOC are not consistent with some of the values of professional social work, one need only to examine the intentions of IOC to know that it is a positive entity. Professional social workers espouse the right of clients to self-determination, empowerment, and dignity to name a few. Although at first glance it appears to prevent clients from exercising their basic rights, IOC actually allows mentally ill clients to improve their quality of life by not being hospitalized in psychiatric inpatient institutions. IOC presumes that certain clients will not be able to acknowledge the utility of receiving psychiatric treatment and, therefore, must be coerced to do so.

Although clients may feel initially as though their civil liberties are being taken away, they will soon realize that the purpose of IOC is to empower them and give them their livelihood and health back. Part Two Drawing on the incremental model of social policy analysis, IOC seeks to continue in the quest of the individuals that devised the policy of deinstitutionalization in the 1960's. The incremental model views current public policy as largely a continuation of past policies marked by only incremental changes, (Haynes & Mickelson, 2003). This model is conservative in that it utilizes existing policies as a baseline for determining the range of possible policy change. The incremental model is less expensive in terms of both the time spent reviewing and projecting alternatives and the costs already invested in existing policies. Consequently, it is a more expedient political model, (Haynes & Mickelson, 2003).

It is undoubtedly the case that the mental health system prefers this model, as it allows them to experience expedient and much needed change. Deinstitutionalization sought to take clients out of restrictive psychiatric institutions and allow them to receive treatment in MHCs within their communities. Unfortunately, however, those who conceptualized deinstitutionalization did not effectively conceptualize the type of mental health services that would be appropriate to serve these clients, and how that treatment could be implemented. IOC draws on the basic concepts of deinstitutionalization, but quantifies them in a way that ensures appropriate treatment. IOC explicitly informs MHCs how to manage particular clients through psychiatric treatment, medications, drug / alcohol treatment, etc. By simply building upon the concepts that deinstitutionalization was developed on, IOC should be relatively successful at rehabilitating clients.

IOC possesses several overstated goals. First, IOC seeks to rehabilitate mentally ill individuals in the least restrictive setting possible. Proponents of IOC recognize that different levels of treatment are appropriate for different types of mental illness. Acknowledging this, IOC seeks to provide treatment that is most appropriate for clients by allowing them to keep the majority of their "lives" intact while receiving treatment. Second, IOC seeks to commit only those who are appropriate while referring others to psychiatric hospitals or voluntary outpatient treatment. As one can easily observe by observing the previously discussed eligibility criteria, IOC successfully weeds out those individuals who are not appropriate for that level of treatment.

Third, IOC seeks to create a trend for clients to continue with treatment, medication compliance, keeping appointments, etc. Research has shown that, in many cases, IOC increases the likelihood that clients will continue to comply with treatment even after their court order expires, (O'Reilly, 2001). These findings prove that IOC teaches clients that treatment is necessary and, therefore, should be strictly adhered to. Finally, IOC seeks to both protect the mentally ill and their communities. IOC is designed to provide rehabilitation and treatment for mentally ill individuals who are perceived to be a risk to themselves or to others. By taking these individuals off of the streets, IOC helps to increase the safety of the client and his / her community.

The understated goals of IOC are to reduce the financial burden of rehabilitating from psychiatric hospitals, and placing it on local communities, and reducing the amount of the money the mental health system spends on rehabilitation. In other words, by requiring that counties fund the treatment of their residents, state mental health systems are able to apply more money to inpatient facilities and other programs. Additionally, by providing short-term, outpatient treatment, the mental health system decreases the amount of money it spends on rehabilitation. I believe IOC can significantly reduce the number of individuals that roam the streets suffering from chronic mental illness by proper and appropriate application of its established goals. First, IOC definitely allows for rehabilitation within the least restrictive setting. Opponents to IOC present inpatient hospitalization or outpatient voluntary treatment as alternatives to IOC.

IOC proponents, however, feel that some of these clients could be successfully rehabilitated within their communities, but only with coercion. As IOC is offered in the clients' communities, I feel that this goal can be attainable in most circumstances. Second, IOC seeks to place only those individuals appropriate for that type of setting under IOC while referring others on to psychiatric inpatient hospitals. By using the stringent criteria discussed above, IOC should be able to appropriately segregate those who are appropriate for IOC from those who are not.

Third, IOC contributes to overall compliance of clients with all components in their treatment plan and court order. Research has shown that, for the most part, this goal is attainable, as many clients go onto to experience an increase in compliance even after their court order expires. Finally, IOC helps increase the protection of the mentally ill and of the public. Research has shown that IOC decreases the likelihood that an individual will be the victim of a crime, and that the individual will be a perpetrator of a crime. It is my opinion that proper application of IOC at all levels, and the assurance of continuity of care will enable IOC to achieve all of its goals. IOC possesses several strengths that should be mentioned.

First, IOC decreases the likelihood of homelessness for those who are severely mentally ill. Research has shown that, for those who possess serious psychiatric diagnoses, IOC is very effective in decreasing the likelihood that they will experience homelessness during and after the court order, (Compton et al., 2003). Second, IOC increases the likelihood that clients will comply with medication regimens. Research has shown that clients tend to experience an increase in medication compliance both during and after IOC, (Swartz, Wagner, Swanson & Elbogen, 2004).

Third, IOC decreases the likelihood that clients will engage in substance abuse and criminal involvement. Research has shown that being remanded to IOC decreases the likelihood that clients will be either the victim or perpetrator of a crime, and that they will engage in substance abuse, (Compton et al., 2003). Fourth, IOC increases the clients' ability to access social resources. While under IOC, mentally ill individuals are allowed to access resources such as substance abuse treatment, community outreach, vocational rehabilitation, etc. that they might not otherwise have access to. Fifth, and finally, IOC decreases the number of hospital admissions by 50-80%. Research has shown that clients that are remanded to IOC experience far fewer hospital readmission's, (Torrey & Kaplan, 1995).

Although IOC possesses several strengths, it also possesses a few weaknesses that should be noted. First, research has shown that IOC is only successful when those admitted have serious psychological disorders. As such, IOC would not be successful for all mentally ill individuals, (Compton et al., 2003). The criteria discussed above, however, seek to eliminate those who are not "suitable" for this type of placement. The fact that IOC has not been shown to be overly successful with individuals who do not possess serious psychological disorders points out that those individuals might be more appropriate for outpatient voluntary treatment. Second, IOC relies on coercion and leverage as a means to get clients to comply with treatment.

Opponents of IOC state that resorting to these means undermines the therapeutic relationship between client and therapist. Research has shown, however, that most individuals remanded to IOC actually report that IOC was in their best interest, (Swartz, Wagner, Swanson & Elbogen, 2004). The increased likelihood of treatment compliance is a testament to the fact that many of these individuals do, in fact, see the benefits of IOC. Third, IOC can sometimes portray the mentally ill to be intellectually incompetent and threats to their communities. Opponents assert that IOC creates a negative stigma for these individuals that they are incapable of determining what type of treatment they need. Additionally, opponents assert that IOC makes the public fear the mentally ill and view them as threats to society, (National Mental Health Association, n. d.

). I feel, however, that IOC shows the public that mentally ill individuals are capable of rehabilitating and that they are not a danger to the community. Nothing speaks more loudly to the public about the instability of a certain individual than inpatient psychiatric commitment, which is what opponents offer as an alternative. Finally, IOC has been found to be successful only if the staff delivering treatment is genuine in their attempt to rehabilitate clients. In other words, if the treatment staff does not wholeheartedly attempt to rehabilitate their clients, the clients will have less of a likelihood of rehabilitating. Part Three There are a few stakeholders on each side of IOC.

Proponent stakeholders of IOC include the mental health system, clinicians, the public, and the criminal justice system. Opponent stakeholders include some social workers, mentally ill individuals and their families, and civil liberty groups. Since they have the most to gain from IOC, clients remanded to IOC will benefit the most from the program. Civil liberty groups have the most to lose from IOC, as they would have to deal with knowing that clients initially lost some of their civil liberties in IOC.

Table 2 exhibits how the various stakeholders view outpatient commitment. The stakeholders in this table include subjects with psychoses, family members of those subjects, the general public, and clinicians. According to all stakeholders, avoiding outpatient commitment is of least concern in comparison to avoiding involuntary re hospitalization, avoiding interpersonal violence, avoiding interpersonal conflict, and avoiding outpatient commitment, (Swartz et al., 2003). In other words, although many believe that many stakeholders involved in IOC would view it as a negative, undesirable entity, research has shown that several stakeholders view it as a desirable, if necessary, entity. Source: Swartz, M., Swanson, J., Wagner, H.R., Hannon, M., Burns, B., & Shumway, M. (2003).

Assessment of Four Stakeholders' Groups Preferences Concerning Outpatient Commitment for Persons With Schizophrenia. American Journal of Psychiatry, 160 (6), 1139-1146. The mental health system supports IOC because it allows them to provide effective treatment to those who truly need it. Additionally, IOC prevents those individuals who do not need to be remanded to inpatient hospitalization from doing so. Especially in this day and time when medical treatment has become so costly, mental health systems would prefer to keep as few clients in their psychiatric hospital beds as possible. Clinicians support IOC because they understand the utility of different levels of treatment for different types of mental illnesses.

In other words, clinicians realize that you cannot send all clients to inpatient hospitals, nor can you expect that all mentally ill individuals will comply with voluntary treatment. The public supports IOC because they feel safer when unstable, mentally ill individuals are receiving treatment. Additionally, the general public views treatment as a positive entity, regardless of where it is administered. Finally, the criminal justice system supports IOC because it alleviates some pressure to house mentally ill individuals in prisons and jails.

Additionally, it ensures that mentally ill individuals receive appropriate treatment, which correctional facilities are not designed to administer. Some social workers might be opposed to IOC because they generally believe in a client's right to self-determination and empowerment. However, I feel that IOC actually does provide clients the right to self-determination and empowerment by allowing them to remain in their communities as opposed to being committed to inpatient hospitals. IOC tells clients and the public that some mentally ill individuals are capable of rehabilitating in a less restrictive environment, and that they are resilient individuals. Although coercive techniques may be used to commit one to IOC, the overall outcome is a positive one. Also, IOC empowers clients by showing them that the system has faith in their abilities and wants to see them succeed quasi-independently.

Mentally ill individuals and their families might be generally opposed to IOC, as they may feel that treatment is not necessary, or that the family can provide a supportive environment. Research has shown, however, that many mentally ill individuals lack insight into their illness and its effect on their lives, therefore sometimes courts must remand treatment. Additionally, family members are generally not trained to provide adequate treatment for their loved ones. Finally, civil liberty groups might generally be opposed to IOC, as they espouse the general belief that people should have all civil liberties intact, regardless of the situation.

When compared to inpatient hospitalization, however, I feel that civil liberties groups might possibly view IOC as an acceptable form of treatment. According to Social Work Speaks, IOC could be considered undesirable because it might discourage individuals from attempting to seek treatment. According to the policy statement on mental health, a shortage of mental health resources has caused some state mental health systems to limit their services to individuals who meet criteria for involuntary treatment. As a result, according to the statement, people who request mental health services because they feel the need for them may be rejected, (National Association of Social Workers, n. d. ). In general, however, most states have not limited services to involuntary commitments only.

Additionally, no research has been presented to show that individuals have been effectively deterred from seeking treatment due to IOC. The national mental health system is largely coordinating efforts to provide for IOC. Influenced by psychiatrists, the criminal justice system, the public at large, etc., the mental health system is working on making IOC more successful by improving the selection criteria and ensuring that quality treatment is being provided. As the gains can be observed, it should be noted that the mental health system has been relatively successful in its efforts. Civil liberties groups, however, are constantly attempting to have IOC banned, as they feel that it is an infringement upon one's rights. For the most part, though, these groups have been largely unsuccessful in preventing IOC from being used for certain individuals.

In my opinion, some social workers are not actively fighting for IOC as they should, as they feel that it tends to conflict with some of their values. I believe, however, that social workers should view IOC as betterment for the clients and, therefore, a positive entity. Even social workers realize that sometimes they must advocate on behalf of their clients when the clients are unable to do so. Just as social workers must occasionally intervene to improve the lives of their clients, IOC must intervene when mentally ill individuals refuse to accept treatment that they desperately need. IOC simply seeks to rehabilitate these individuals and give them a second chance at life.

I believe social workers should join the fight to help gain more money from the federal government to support IOC and other similar programs. By advocating for the mentally ill and lobbying for more money, I feel that we might be able to significantly reduce the number of mentally ill individuals that are not receiving appropriate psychiatric treatment. I feel that it is immensely important for social workers to understand IOC, as it directly impacts a population that is largely untreated and misunderstood. The government made the mistake of releasing many of these individuals in the 1960's without ensuring that they had a "safety net". We must now do what should have been done many years ago-offer a program that successfully and wholeheartedly attempts to rehabilitate these clients in the least restrictive setting possible.

Without people like social workers to advocate on their behalf, the mentally ill can expect to struggle through another few decades without receiving adequate and appropriate treatment. Conclusions IOC appears to be supported and embraced by the majority of the public, as evidenced by its existence. As more people become educated about the benefits of IOC, I believe it will realize more support at all levels. I feel, however, that it is going to be increasingly important for all involved systems-social, civil, criminal, etc. -to be supportive of IOC for it to succeed.

If all systems can come together in support for IOC, it will have a better chance of surviving and providing quality treatment. The only current suggested alternatives to IOC are inpatient hospitalization or voluntary outpatient treatment. Inpatient hospitalization takes all autonomy away from the client-something social workers should never advocate. Voluntary outpatient treatment relies on the assumption that the mentally ill possess insight into their illnesses and, therefore, will comply with treatment. Research has shown, however, that many mentally ill individuals lack adequate insight into their illness and its affect on their lives.

Additionally, many individuals will not comply with treatment when they have not had to do so in the past. IOC, however, sets up a pattern for which this behavior becomes more likely. Based on these facts, I do recommend IOC as it is currently stated. As discussed above, I feel that IOC would be most effective if other components were combined with it, if there was a way to ensure that treatment staff wholeheartedly attempts to rehabilitate individuals, and if treatments last longer than six months. Additionally, more money needs to be supplied to local mental health centers to ensure that treatment is adequate. Although many might oppose more money going into a service sector that they believe is already receiving too much money, I believe if social workers and other mental health advocates could show the public how necessary IOC is, getting an increase in resources would not be difficult to procure.

In closing, IOC was created to serve those mentally ill individuals who need treatment, but not necessarily in an inpatient setting or through voluntary treatment. IOC possesses several strengths that exhibit its utility in today's society. As social workers, although we may disagree with the coercion element of it, we should endorse IOC, as it only betters the lives of mentally ill individuals who are largely misunderstood, largely under treated, and largely deserving of our support.