Outpatient commitment laws, passed by a number of states, permit forced commitment to treatment of those whom a psychiatrist, psychologist, or mental health official deems in need of treatment. The majority of this “treatment,” while not specifically stipulated in the law, results in coercive tactics to pressure agreement to take pharmaceutical preparations of limited-to-no effectiveness but – as shown in early research – with massive effects on cognitive functions and subsequent decision-making ability, not to mention a long-term or lifelong diminished quality of life and ability to function as a productive member of society.
Lately, however, research into the effectiveness of coercive treatment has been comparatively defunded, given the prevalence of pharmaceutical industry dominance in antipsychotic research. When such an approach is scientifically justified, that is one thing. Numerous research studies over the past 60 years have established that an enhanced voluntary services program for those diagnosed as “mentally ill” and incentive programs, including housing programs – are far more effective and consistent with social justice concerns than an involuntary commitment program, especially financial incentives used to gain cooperation by people with difficulty in functioning in society but resistant to current treatment.
New York State instituted an outpatient commitment law, “Kendra’s law,” about 15 years ago. While the NYS Office of Mental Health, in an assessment of the law’s effectiveness, specifies there is no racial disparity in its application, one only need look at the statistical database to see that there is certainly racial disparity. An analysis of NYC’s outpatient commitments by Kendra’s law between 1999-2010, presented in the following table, clearly indicates prima facie racial discrimination:
Racial Characteristics From NYC Census
NYC Pop. Census Kendra NYC Commitment
African Am. 15.9% 36%
Latino(a) 17.6% 38%
Asian 12.7% 3%
White 65.7% 23%
In California, the Orange County Board of Supervisors are now preparing to adopt “Laura’s Law,” identical to New York’s Kendra’s law in its emphasis on legal outpatient commitment. The Board of Supervisors have been presented with research data clearly indicating that legal forced commitment to treatment is less effective than voluntary enhanced treatment.
The Psychiatric Rehabilitation Association has repeatedly stated its strong opposition to involuntary outpatient commitment as presented in the association’s recent 2013 statement:
“Recovery is possible when the individual in treatment acts in partnership with the rehabilitation workforce and strengthens integration into their community; coercion is not an incentive to recover and all too frequently may be implemented where other treatment and community support options could achieve a better result.”
However, most recently following the reaction to the Orange County press coverage of the killing of a “mentally ill” individual who was beaten to death by police (currently under review by the US Dept. of Justice), the false conflation of violence and mental illness has reemerged, resulting in legislative officials ignoring the worldwide research on the ineffectiveness of outpatient involuntary commitment when compared to the effectiveness of increased funding for enhanced voluntary mental health services. The real problem in the killing was the ineffective training of the police in dealing with a supposedly “mentally ill” individual, who was sitting at a bus stop when confronted and repeatedly stated he was doing nothing wrong. He was badly beaten and died of his injuries.
What would likely have saved him is a liaison with the Fullerton Police of a local mental health agency clinical staff person, on call for every encounter with a potentially “mentally ill” individual. We had this in the 70’s when I worked as a young clinical psychology post-doc intern at a California Community Mental Health Clinic. I recall going out in the middle of the night with Sheriff’s deputies. In other major metropolitan areas, I subsequently participated in training sessions with SWAT team members and other police on how to relate to a disturbed person. One has to wonder what happened to this system. A legal outpatient commitment would not have saved this person from being beaten to death, yet the public and the Board of Supervisors are supporting outpatient commitment as a reaction, not based on reason but on the public’s unwarranted fears and basic ignorance of those who are diagnosed as mentally ill.
Parents dealing with disturbed young adults, as well as parents’ groups, embrace the false belief that a legal outpatient commitment to treatment will provide a solution. This is compounded by the well-funded and nationally organized distortions of research presented by the Treatment Advocacy Center (TAC), an organization created after the National Alliance for the Mentally Ill (NAMI), posing as a parent advocate group, was discovered by Senator Grassley’s group and investigative reporters to be covertly funded by the pharmaceutical industry. TAC was formed by a former NAMI creator and his associate from the advertising industry. This action served to distance themselves from NAMI. Both groups have distorted and denied significant research that disagreed with their opinions. TAC is funded by a corporation that engages in pharmaceutical research, the Stanley Foundation. Soon after TAC’s formation, the former advertising industry person reportedly suggested they falsely conflate mental illness with violence to elevate the public fears so that laws will be passed to promote their views and manipulate the mental health industry, state, and local governments to succumb to their unscientific beliefs. The ultimate, transparent goal of their strategy is to legally force all whom they deem in need, into pharmaceutical treatment.
Sound research repeatedly proves most of their assumptions, beliefs, and proclamations are in serious error. Yet their target audience is the general public, for purposes of generating fear. The public does not necessarily follow the scientific research on these issues. Not many citizens are aware of the serious detriments to an individual’s mental health, physical health, and the financial implications of implementing a law requiring involuntary commitment. If such a law proved scientifically valid, the effort might be justified. But studies, including those reviewed by the Rand Corp, cited below, proves that it has little if any scientific support. In fact, a far less expensive enhanced voluntary services program has proven, in numerous international studies, to be far more effective.
California counties with large populations will incur significant unanticipated court and legal costs if they implement the law. In Orange County, south of Los Angeles, the county behavioral health director who is reportedly in support of implementing the law, recently indicated in the press that it would apply to “120” clients. While the state will provide some funds if the county implements the law, the costs for those 120 could well exceed $50 Million to the county, over what will be provided from the state, including court operating costs, attorney fees, salaries for involved police and sheriff deputies, salaries for mental health officials involved, state mandated enhanced services, and oversight. The conclusion of the recent Rand Corp. study on the matter, updated November, 2012 is quoted here:
“A RAND team led by Susan Ridgely reviewed the available studies, interviewed stakeholders in eight states, and analyzed administrative data on services provided by California’s county mental health contract agencies. Their conclusion:
• There is no evidence that a court order is necessary to achieve compliance and good outcomes, or that a court order, in and of itself, has any independent effect on outcomes.”
A far egregious matter involves how the law is applied. Martin Luther King’s dream of a post-racial America has not been achieved, regardless of popular rhetoric. This fact is clearly reflected in the racial disparity in our major institutions, corrections, and mental health. Significant evidence that the local, state, county, and federal mental health systems and agencies are racially biased – albeit subtly – is denied in most cases. Since at least the 1960’s diagnostic research has demonstrated a racial bias in psychiatric diagnosing, where major mental illnesses are over-diagnosed in ethnic populations. Much of this is swept under the rug.
In the 1980’s, a colleague, preferring anonymity, who had previously worked as a tenured university professor teaching experimental psychology, took a job as a program evaluation director in a major California psychiatric hospital. His position included publishing studies. One such study he was about to publish established a statistically significant racial bias in discharge planning of African Americans and Mexican-Americans who identified with their Mexican culture. Administrators threatened him with a search warrant of his private residence if he did not produce all copies of the original data of the study. He was eventually removed from his position and forced out of the job (personal communication).
Within the past decade before retiring, prompted by curiosity why the hospitalized population represented a far greater proportion of African Americans, I completed an informal study of race-based diagnoses at a major metropolitan forensic hospital where I held the title of director of program evaluation. An African-American, Haitian-American or other black person on admission had (if memory serves) a 70% chance of receiving a schizophrenia diagnosis compared to less than a 50% chance of a white person or Asian person walking through the door. Odds for a Latino of a schizophrenia diagnosis was around 60%. Many formal studies confirmed similar racial disparities.
The psychiatrist and scholar Jonathan Metzl, in his 2010 book The Protest Psychosis presents confirming data that the diagnosis of schizophrenia has become racialized, a “black disease,” as many activists and civil rights protestors have fallen under the eye of the mostly white psychiatric system run by white-privileged psychiatrists, psychologists, and other white mental health professionals. Experience as well as research informs us that people of different ethnicities who present anger and opposition at being institutionalized or forced to be evaluated by white professionals or ethnic professionals identifying with the white mainstream are labeled with one of the variants of “schizophrenia,” most commonly paranoid schizophrenia.
How does this racial diagnostic disparity bear on the implementation of an outpatient commitment law in California, or any other state for that matter? One need only look above at the NYC statistics on racial disparity in the implementation of Kendra’s law to see how it will apply if Laura’s law is implemented. Based on solid research over the past 15 years of similar laws, it is anticipated that the implementation of Laura’s law will result in racial disparities, opening Orange County and other California counties once again to civil rights lawsuits, judgments, and other unanticipated expense to taxpayers but negative – if any – benefit to the people who happen to fit the criteria for legal outpatient commitment. A criteria, based on opinion, not sound science.
In reviewing the world’s history of treatment of mental difficulties, one can discover numerous instances of effective creative approaches. All states, including California, need an enhanced mental health program that transcends the rigidly uncreative mainstream operation that it now is, not another law based on a knee jerk reaction as was done with New York’s Kendra’s Law. As a result on the law becoming institutionalized, NYS Mental Health officials continue a strategy to obfuscate its true ineffectiveness: an oppressive law that is based on opinion, naiveté, knowledge deficits, and ignorance of what really does work, while ignoring more than 60 years of worldwide research that mostly opposes it. The people of California need a mental health system, reorganized in a creative fashion, utilizing positive and relevant contingency management or motivational incentives to encourage those reluctant to accept involvement to attend voluntary programs. They certainly do not need another law that harms the public welfare, benefitting political agendas while creating more pain, suffering, and alienation for those in our society who are most needy.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.