What's at Stake When Race and Coercive Mental Health Treatment Collide?

In 2009, a team of Duke University researchers set out to answer one of the thorniest questions at the intersection of mental health policy and race: Is the practice of involuntary outpatient commitment used more often with African-Americans than whites? And if so, what does that mean?

It was an important question to answer seven years ago. It's even more important now, on two fronts.

We're at a moment in the nation's political consciousness when issues of race and state coercion are at the forefront. We also, somewhat coincidentally, may soon see the largest structural change to the nation's federal mental health care system in decades, with reform bills currently under debate in both houses of Congress.

Both bills include increased funding for state programs that support involuntary outpatient commitment, or assisted outpatient treatment as it's sometimes known. The practice allows judges to order people with serious and persistent mental illness to involuntary outpatient treatment plans even if they haven't broken any laws or reached the threshold for inpatient commitment.

It's an issue that has divided the mental health community to a rare extent. For its advocates, it's a humane alternative to leaving people to deteriorate to the point where they'll end up in jail, on the streets, or in acute crisis. For its critics, it's an unnecessary and potentially traumatic act that violates people's civil liberties and serves politically as a deflection from the real problems facing the mental health care system.

From either direction, questions over racial disparities need to be recognized and addressed sooner rather than later. We have to pay close attention, in other words, to the answers from that 2009 paper, and perhaps even closer attention to the much larger structural questions the researchers candidly admitted they couldn't answer.

The researchers found that in New York, where the study was conducted, African-Americans were over-represented by a factor of five, compared to whites, among those mandated to outpatient commitment.

Upon closer inspection, the data showed that the reasons for this difference aren't likely to be any bias or prejudice at the moment a clinician recommends outpatient commitment, or a judge orders it. Instead, it's pre-existing disparities in factors like poverty, severe mental illness, and public hospitalizations.

In this realm, as in so many others, our nation's history of racism and discrimination has rendered African-Americans more vulnerable and exposed. And these fundamental disparities have to inform the questions we ask about public policy.

Loss of autonomy over one's own life and choices matters to all of us, of all races, but it may matter more when state coercion is applied to people from groups that have historically been subject to horribly unjust and destructive state coercion. It may mean that the protection of autonomy and liberty, for a person of color, should weigh heavier in the balance against the potential good of the forced treatment.

These aren't easy concerns to balance. But the federal mental health care system, and any new laws that change it, can and should address them. There is more research to be done on potential disparities at all levels of the mental health care system. There is more work to be done integrating cultural and linguistic competency into the mental health care system. There is more research needed on the outcomes of outpatient commitment programs.

Above all, we all have a responsibility to make sure that we are not perpetuating a broader system of racial injustice and disparity. We have to be vigilant, particularly when it comes to programs that are coercive. The existing research on the outcomes of such programs is mixed, but even if they are beneficial, it is no guarantee that if the practice is expanded at the state level, each program in each state will be beneficial. If history is any guide, what may work well in New York for example, without bias or prejudice, could become something discriminatory and destructive in another state.

If lawmakers do end up moving forward on increased funding for involuntary outpatient commitment, let's put measures in place to study the outcomes, identify racial differences and potential disparities, and revoke funding if state programs prove ineffective or discriminatory.