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.

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.

One means to address some of the unintended consequences of the shift of treatment for individuals with serious mental illness from hospitals to communities has been involuntary outpatient treatment (IOT). Using Massachusetts data, 19 patients with court orders for IOT were matched to all and to best fits on demographic and clinical variables, and then to individuals with the closest fit on utilization before the IOT date. Outcomes indicated the IOT group had significantly fewer admissions and hospital days after the court order. The full impact of IOT requires more study, particularly directed toward IOT's effects on insight and quality of life.

A quasi-experimental study of involuntary outpatient treatment in Massachusetts is described and analyzed. Results indicate decreased hospital use by the involuntarily treated outpatients, which may or may not be due to the involuntary intervention itself.