Involuntary outpatient treatment as "desintitutionalized coercion": the net-widening concerns.

In American jurisprudence, two justifications have traditionally been put forth to support the government's social control of persons with mental illness: police power and parens patriae. As public mental hospitals became less available as loci in which to exercise these functions, governments sought alternative means to achieve the same ends. One prominent but quite controversial means is involuntary outpatient treatment (IOT). While the concerns about IOT have been myriad, one often alluded to but never documented is that of "net-widening." That is, once IOT became available, it would be applied to an ever greater number of individuals, progressively expanding the margins of the designated population to whom it is applied, despite the formal standard for its application remaining constant. We tested the net-widening belief in a naturalistic experiment in Massachusetts. We found that net-widening did not occur, despite an environment strongly conducive to that expansion. At this time, whatever the arguments against IOT might be, net-widening should not be one of them.

Behavioral health electronic medical record.

The electronic medical record (EMR) will be an important part of the future of medical practice. Behavioral health treatment demands certain additions to the capabilities of a standard general medical EMR. The current focus on the quality management and financial aspects of the EMR are only initial examples of what this tool can do. It is important for behavioral health practitioners to understand that they must embrace this innovation and mold it into a product that serves their needs and the needs of their patients. An efficient and effective EMR will greatly assist the overall clinical enterprise in a number of important areas.

A competency-based approach to managing violence with involuntary outpatient treatment.

Involuntary outpatient treatment is one of the most controversial areas in public psychiatry. There are cogent arguments and strong emotions both for and against the use of it. Yet there is violent behavior towards others by individuals with mental illness who reside in the community that is not managed well even when recognized as highly likely. For individuals already in the community mental health system, the ability to keep them in treatment, even against their will, is necessary in some instances to decrease the likelihood of them engaging in outwardly directed violent behavior.

Public sector risk management: a specific model.

Risk management programs for state mental health authorities are generally limited in scope and reactive in nature. Recent changes in how mental health care is provided render it necessary to redirect the risk management focus from its present institutional basis to a statewide, network-based paradigm that is integrated across public and private inpatient and community programs alike. These changes include treating an increasing number of individuals in less-secure settings and contracting for an increasing number of public mental health services with private providers. The model proposed here is closely linked to the Quality Management Process.