Commentary: the search for a formula to relate competence, coercion, and mandated treatment.

The article entitled “The Perceived Coerciveness of Involuntary Outpatient Commitment: Findings from an Experimental Study” offers an important evolution in an area that informs the mental health law and policy debate on mandating treatment. Swartz et al., and in particular the John D. and Catherine T. MacArthur Foundation, are to be commended for their continued commitment to understanding the impact of the violence-competencecoercion triad on development of mental health policy. It is, however, the promise of an elaboration of the generated data, which the authors suggest may be available, that offers the most hope for answering difficult questions. It is hardly news that persons subject to outpatient commitment (OPC) perceive themselves to be coerced. It is important that analysis of the data gathered demonstrate a link between a greater level of perceived coercion and poor insight into illness (among others). If, as the authors suggest, further analysis can contrast the perception of coercion among persons who improve and do not improve under OPC, then as the authors hypothesize, we may be able to determine whether some lost autonomy is to be tolerated if outcomes improve. Society yearns for simple black-box solutions to difficult problems. If the subject is guilt or innocence, we turn to lie detectors, breathalyzers, and DNA testing. When the problem is mandated treatment of any kind, we seek algebraic-like equations so that subjective moral judgments can somehow assume a mantle of objective justification. The ability to determine with some degree of uniformity, when and to what degree coercion is appropriate (if ever) in the treatment of disease, and in particular the treatment of mental illness, has long been a goal of behavioral science literature and research. We seek a formula to predict appropriate levels of coercion by factoring a risk/benefit analysis, with elements of violence risk-potential assessment and an allowance for competency. The result could then be considered while applying the appropriate standard of proof: “the degree of confidence our society thinks [the decision maker] should have in the correctness of factual conclusions for a particular type of [decision].” High risk of violence potential, coupled with treatment demonstrated to be efficacious for this individual, may, for example, require proof of incompetency to be supported by only a fair preponderance of the evidence and may tolerate some level of coercion. Low risk coupled with a moderately effective treatment regimen may require proof of incompetency beyond a reasonable doubt and may tolerate little loss of autonomy. If not justifying the means, this would at least allow the clinician some comfort level when making the decision to intrude on personal autonomy. From 1955 to 1998 the state hospital inpatient population in the United States dropped from its peak census of approximately 559,000 to 57,151. There are many factors that contributed to this decrease. Some of the most salient of these include the introduction of effective pharmacotherapy in the 1950s, the amendments to the 1935 Social Security Act that created supplemental security disability income (SSDI) in 1956, Medicaid and Medicare in Mr. Grudzinskas is Assistant Professor of Psychiatry in Law, Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA. Address correspondence to: Albert J. Grudzinskas, Jr., JD, Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Avenue North, Room S7-802, WSH-8C, Worcester, MA 01655. E-mail: al.grudzinskas@umassmed.edu