Introduction
Involuntary psychiatric commitment can be seen as the reformed version of mental asylums, as it forcibly holds people for about 72 hours and involves non-consensual psychiatric care. Protocols may differ by state and sometimes by county; additionally, holds can last longer 72 hours if psychiatrists or physicians deem it necessary. Restrictive practices like isolation or seclusion, physical restraints, mechanical restraints (e.g., handcuffs), and chemical restraints (e.g., sedatives and tranquilizers), can be used as a last resort in the name of safety of the patient and others. Some racial/ethnic groups are at greater risk of being placed in involuntary psychiatric holds and are more likely to be placed in facilities by law enforcement officers due to systemic inequalities and lack of alternative interventions. Patients have minimal autonomy until they can be seen in front of a judge at a court hearing to prove their competence and well-being. While the impacts of involuntary psychiatric commitment are understudied, research shows that this practice is increasingly occurring (Bhalla et. al., 2022).
A systematic review of 27 research articles examined themes regarding coercion and involuntary commitment. Researchers found that in qualitative studies on the emotional consequences of involuntary commitment, themes of loss of autonomy, low self-esteem, and strong emotions like feeling devalued, stigmatized, and dehumanized were found to be common experiences (Newton-Howles, 2011). Due to overwhelmingly negative associations with coercion, researchers believe that clinicians should reexamine beliefs that coercion is a possible beneficial treatment for patients. In a Florida study, researchers conducted 40 in-depth interviews with youth and young adults who were involuntarily committed in their youth to explore their engagement with mental health resources post-discharge. They found that many participants were more discerning post-discharge about disclosing feelings of suicidal ideation to mental health providers out of fear of being sent back to involuntary commitment. Participants reported censoring themselves and not talking about their mental health to anyone post-discharge because of prior experiences with involuntary commitment. Few participants spoke about the indirect benefits of their hold, such as family becoming more understanding and receiving access to medication. Many participants compared their hold to incarceration due to practices such as strip searching and handcuff use (Jones et al., 2021). Further studies are needed to explore how ethnicity and race play a role in patients’ experiences with involuntary holds.
The use of involuntary psychiatric holds remains an understudied practice, particularly for people of color, despite this population being disproportionately impacted. In particular, poverty and discrimination are risk factors that contribute to individuals experiencing a mental health crisis (Knifton & Inglis, 2020). This supports existing literature that suggests that Black people are more likely to be subjected to restrictive practices in psychiatric treatment. A fairly recent longitudinal study in Boston examined racial and ethnic disparities in involuntary commitment. Researchers followed a sample size of approximately 4,300 admitted patients (28% involuntarily admitted) from 2012-2018. They found that in comparison to White people, people of color were more likely to be involuntarily committed (Shea et al., 2022). A weakness of this study is that it only examined one psychiatric general hospital in one city, limiting its generalizability, since laws and procedures vary across states and sometimes counties. Researchers noted that ethnic and racial inequities should be considered in future research for alternative interventions that reduce reliance on involuntary commitment.
Researchers Singal et al. (2024) analyzed a retrospective chart review of medical records from patients both involuntarily or voluntarily admitted from the years 2012-2019. Racial disparities in frequency and duration of restrictive practices in involuntary commitment were examined. They defined restrictive practices as "physician-ordered physical or mechanical holds.” They found that being Black was associated with longer restraint duration and that Black and multiracial patients were more likely to experience restrictive practices than White patients in a sample of over 29,000 patients. They posit that longer restraint times for Black and multiracial patients suggest racial bias in mental health providers. One limitation of this study was potential error in data entry, as providers are likely to prioritize securely restraining a patient over recording the instance during the active restraint of a patient. These findings contribute to existing literature that demonstrates racial disparities specifically in involuntary psychiatric holding and highlights the importance of cultural competency training for clinicians.
Cultural competency involves being aware and responsive to the values and perspectives of different cultures (Stubbe, 2020). There is a long recorded history of medical abuse against people of color in United States health care settings, such as the forced sterilization of women of color across the United States and the Tuskegee Syphilis Study, where many Black men and their family members with syphilis died due to researchers purposefully withholding available treatments from them (Alonso, 2020; Nuriddin et. al., 2020). In both examples, people of color were stripped of their autonomy, denied their right to informed consent, and coerced into receiving medical treatment. Previous research suggests that cultural competency can aid in reducing racial disparities and inequities within health care. The history of racial inequities in health care should be taken into consideration in the clinical decision-making of involuntary commitment. With this in mind, cultural competency training varies widely among psychologists. Currently, there is no consistent standard across psychology programs for cultural competency training. One clinician might misinterpret cultural dialect and send their client to be involuntarily committed due to a lack of cultural competency.
One study followed graduate students who went through cultural competency training (Benuto et al., 2018). When trainees were involved in service learning (i.e., learning through community service), researchers observed recurring themes in their journal entries that documented their thoughts before, during, and after helping ESL students learn English. Themes such as “a change in diversity attitudes; growth in their multicultural counseling competence, counseling skills, and leadership skills; an increased awareness of the need for multicultural competency; increased knowledge; and an increased appreciation of individuals who are different than them” frequently showed up in the journal entries of these trainees. This study found that trainees reported the most useful parts of the training were exposure to other cultures, cross-cultural contact, and guest speaker presentations. It seems that learning accurate and historical information about other cultures was important to the trainees who participated. These results align with results from other studies and should serve as guidelines for clinicians (Díaz-Lázaro and Cohen, 2001; Neville et al., 1996). Including learning opportunities, such as the one described in this study, in cultural competency training for clinicians, as well as specific, evidence-based methods of cultural competency training should be encouraged by the American Psychological Association (APA).
In a systematic review of 17 articles that touch on cultural competency training in psychology, there was one study that looked into whether training produced positive outcomes for the clients of the clinicians (Evans et al., 1984). The training that these clinicians underwent produced more positive patient satisfaction ratings post-training compared to pre-training. Further studies that examine patient satisfaction are critical, as high satisfaction can represent a positive therapeutic relationship, which is one of the desired outcomes of cultural competency training. This review found that how cultural competency training is conducted is not explicitly mentioned in many studies. More specificity about training methods is important to understand what aspects of training are creating changes and what gaps can be filled with evidence-based practices to promote efficacy (Benuto et al., 2018).
The decision of sending someone to involuntary psychiatric commitment is up to mental health providers’ discretion. The research is limited on what treatment cultures or ideologies clinicians use to make decisions about reporting clients to be hospitalized involuntarily (Kaltiala, 2022). Additionally, there are no standardized procedures or guidelines for clinicians to utilize when making these critical decisions. Although the American Psychological Association has released guidelines for psychologists to incorporate cultural competency in their work, there are limited studies on whether training has made any actual impact on cultural competency in psychology (Benuto et al., 2018). Additional research is needed to implement evidence-based cultural competency training guidelines and practices. The lack of standardized procedures or guidelines regarding cultural competency training for clinician decision-making should be addressed in future literature.
Enhancing culturally competent psycho-education for clinicians can improve understanding and support for individuals undergoing risk of being involuntarily held. The decision of sending someone to involuntary psychiatric commitment is up to the mental health provider, law enforcement officer, or first aid responder’s discretion. Clinicians should take into consideration the long history of coercive care, medical abuse, and people of color being stripped of their autonomy in the United States when working with patients of marginalized identities. This understudied topic is extremely relevant for providers, as their level of cultural competence can influence the decisions they make on behalf of their clients. Their decisions ultimately affect their clients’ well-being, a top priority for providers.
Suggested Future Directions
Future research can help answer the following question: how does cultural competency training affect the factors that providers consider when deciding to report a client to involuntary psychiatric commitment? A qualitative method will be beneficial for this topic in order to gain a deeper understanding of participants' experience with involuntary psychiatric commitment decision-making for their clients. Future studies should consider utilizing an interpretative phenomenological analysis (IPA) framework to focus on understanding an individual's subjective and personal experience of this phenomenon. IPA allows themes to emerge from data rather than analyzing data with existing categorized themes. Future studies should also expand participants to include licensed or in-training mental health service providers such as psychologists, counselors, social workers, marriage and family therapists, psychiatrists, psychiatric nurses, and graduate trainees in mental health fields. When measuring how cultural competency training impacts providers’ decision making, cultural competency training can be defined as having done the following: taken a graduate school course in diversity, received supervised clinical experience with diverse populations from a supervisor with years of cultural competency practices, didactic training about cultural competency, and experiential activities. This definition is based on a 2019 study by Benuto et al. that investigated psychologists' experience with graduate school cultural competency training. The activities mentioned above were the most commonly used and are activities that psychologists were highly satisfied with.
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