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11 Dev. Mental Health L. 1 (1991)

handle is hein.journals/dvmnhlt11 and id is 1 raw text is: Volume 11, Number 1

January - Jun. 1991

Developments in
Mental Health Law

I Institute of Law, Psychiatry and Public Policy

Outpatient Commitment:
Adapting Forensic Models to the Civil Context

by Stuart B. Silver, M.D.

When I first heard the idea of outpatient civil
commitment proposed in Maryland, I reacted with
horror. As the director of the forensic hospital in a
state with a long history of conditional release, I was
probably more acutely aware of the implications of this
mandate than were many of my colleagues. Our
hospital had been responsible for supervising a manda-
tory outpatient program for insanity acquittees since
1967. The conditional release law provided a mecha-
nism to enable the community to have some degree of
comfort when discharging patients who were charged
with felonies and found insane. The program has
increased in intensity, complexity, and in the level of
scrutiny since its inception.
Families pressed for outpatient civil commit-
ment as a way to coerce ill relatives to receive care and
not miss their prescribed medications. The mental
health director looked for a mechanism to reduce the
census of the state hospitals and help the system cope
with insufficient resources. Legislators thought that
this would be an acceptable method of encouraging
community care, while minimizing the risk of disrup-
tive behavior by mentally ill persons on the streets of
constituents' neighborhoods. In contrast, legal aid
attorneys and the public defender expressed skepticism
about the wisdom of creating a new compulsory
mechanism; I was
concerned about the cost,
complexity, potential for            Also in
expanded liability, and
absence of useful sanc-   In the Virginia court
showed little enthusiasm  In the Federal courts
for the idea. The notion
Stuart B. Silver, M.D. is the  Cases from Other St:
Director of the
MarylandMental        In the Virginia Gene]
Hygiene Administration.

that outpatient civil commitment could be a mechanism
to prevent hospitalization rather than shorten it was not
well articulated. The underlying premise that a judge's
admonition would have more influence on a psychotic
patient's behavior than would the advice of family and
physicians was not opened to meaningful dialogue or
scientific inquiry. When a bill to authorize outpatient
commitment was presented to the legislature, the
measure failed.
As director of Maryland's Mental Hygiene
Administration, I have a renewed interest in consider-
ing not only the strategies for outpatient civil commit-
ment, but also the entire involuntary commitment
process including the current criteria we use. Preparing
this paper has challenged me to approach the subject
with a new perspective. I am told that this is dangerous
territory; I am inclined to believe that.
First, I want to examine the evolution of
conditional release in Maryland; then consider the
broader applicability of some of our forensic experi-
ences. I will conclude with a summary and some
reflections on the relationship between outpatient civil
commitment and forensic programs.
Maryland's outpatient conditional release
statute, which went into effect in 1976, required that
the Mental Hygiene Administration monitor discharged
insanity acquittees for
their compliance with
s issue:                 specified treatment
oriented stipulations.
Included in early proto-
cols were instructions on
clinic appointments,
............... 10       medications, and em-
ployment, as well as
S13                      adm onitions against
alcohol and substance
ssemblv ......... 16     abuse, use or possession

The University of Virginia I

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