The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices

U.S. society is undergoing a fundamental transformation that is creating increased awareness of racial inequities in all domains of life, including in personal and public health. As a result, many medical institutions and clinicians are examining how the processes and practices of general medical and psychiatric care explicitly or implicitly contribute to stark racial inequities. Acknowledging and examining these inequities has also revealed that the customary ways of conducting clinical and public health research are insufficient for identifying and dismantling systemic inequities and thus demand a paradigm shift. This shift has begun to generate earnest investigations of the production and reproduction of racism in health care systems and in research. These investigations allow for novel research questions and examination of less researched phenomena that had been ignored because they were deemed epidemiologically insignificant rare events, taken-for-granted practices, or routine ways of providing care. Examples of this new research gaze are provided in two articles recently published in this journal: one on racial-ethnic inequities in inpatient psychiatric civil commitment, by Shea and colleagues (1), and one on racial-ethnic disparities in psychiatric decisional capacity consultations, by Garrett and colleagues (2).

These articles on how race and ethnicity may be associated with involuntary psychiatric commitment and with requests for decisional capacity consultations are salient because they focus on systemic inpatient practices that are inscribed in laws and hospital policies and are intended to protect patients from harm. Both articles found that race-ethnicity matters in these decisions. The Shea et al. analysis (1) indicated that patients of color—that is, all “non-White patients” (as defined by Shea et al.)—were significantly more likely than White patients to be subjected to involuntary psychiatric hospitalizations. Similarly, Garrett et al. (2) showed that Black and Latinx inpatients were significantly more likely than White inpatients to be subjected to psychiatric evaluations of decisional capacity. We commend both research teams for conducting these analyses, which shed light on several less recognized ways in which racial inequities are being reproduced in psychiatric practice. Below, we discuss four of these ways.

Power Imbalance Between Patients and Providers

First, research on racism in routine psychiatric practice, such as hospitalizing patients for 3 days against their will or questioning patients’ judgments and overriding their health-related decisions, has revealed the authority psychiatric clinicians hold over their patients. This power imbalance between patients and providers is amplified by the fact that most psychiatric clinicians are non-Latinx White, whereas most of their patients belong to minoritized racial groups, thus mirroring and reproducing racialized societal power imbalances (3). Enhanced medical training that critically reveals the structural racial-ethnic inequities in clinical practice and health care systems has the potential to, first, increase clinicians’ awareness of their own explicit or implicit biases, and second, to challenge clinicians’ assumptions that they have been practicing patient-centered care. Although both realizations are likely to generate discomfort among clinicians, each can also contribute to self-reflexiveness and humility. These approaches to care, in turn, can begin to mitigate the adverse consequences of the power imbalance between patients and providers, which has been exacerbated by racial-ethnic power imbalances conferred by the false assumption of White supremacy (4).

Involuntary Psychiatric Commitment and Decisional Capacity Consultations

Second, both articles focus on instances where routine patient-provider communications and interactions fall apart and thereby create a need for involuntary commitment or capacity consultations. We suggest that these experiences in the provision of care are what Merton (5) called “strategic research events” (SREs). SREs are events that, when examined, reveal with exceptional clarity the fundamental features of the phenomenon under investigation (i.e., the racist nature of the patient-provider interaction) and provide a comprehensive understanding of the phenomenon. SREs also raise new salient questions for similar phenomena, in this case wanting to leave the hospital against medical advice, which occurs disproportionately among Black patients and is a common reason for seeking a capacity consultation and involuntary commitment (6). Understanding what contributes to these rifts in interactions between providers and minoritized patients is necessary if we are to avert their occurrence and the reproduction of racial-ethnic inequities (i.e., racism) in health care.

We propose adopting an interactionist research approach—that is, one which recognizes that patients and providers jointly construct their relationship and thus assesses the provider’s and the patient’s perspectives instead of attributing rifts solely to patients and to their characteristics (e.g., primary psychiatric diagnosis, educational level, housing situation, race-ethnicity) (7). Relatedly, we also suggest expanding how health care research is conducted by including qualitative data to better examine how patient-provider interactions unfold in health care institutions. Medical records data, typically used to assess involuntary psychiatric commitment and requests for decisional capacity consultations, can be complemented with data from institutional ethnographies, that is, observational data on patient-provider interactions and institutionally produced textual data (e.g., hospital memoranda regarding involvement of security staff or use of patient restraints) (8). These data will reveal how the institutional context (e.g., patient-to-provider ratio, presence or absence of addiction specialists or of bilingual social workers) generates pressures, practices, and policies that impinge on patient and clinician behavior and contribute to involuntary commitment, capacity consultations, discharges against medical advice, and other instances of miscommunication that reproduce racism in health care settings.

Limited Integration of Theories From Social Sciences Into Psychiatric Research

Third, the experience of being held in the hospital involuntarily or of having a psychiatric clinician question one’s capacity to make choices challenges the patient’s autonomy and personhood, and, as the Garrett et al. (2) article claims, this challenge can have “significant implications for the perpetuation and worsening of the patient’s vulnerability in the health care system.” We appreciate the authors’ recognition of the dehumanizing potential of routine health care practices that are supposed to protect patients and, moreover, of the adverse long-term effects of such practices. Therefore, to better understand the long-term effects of adverse experiences of patients in health care settings, and as part of the shift in the research paradigm, we also propose the integration of new or less well-known theories from social sciences into research on psychiatric practice and health disparities. Health disparities studies are largely atheoretical or can be classified into two polar categories that are guided by a few overarching theoretical frameworks that cover the macro, structural level (e.g., the framework of fundamental causes of health inequities) or the micro, individual level focusing on patient behaviors (e.g., behavioral model for vulnerable populations) (9, 10). Theories that bridge the two levels and, moreover, account for life-course processes, such as lifelong exposure to discrimination and systematic exclusion from health-related opportunities (e.g., high-quality health care and housing, well-paying jobs, and resource-rich neighborhoods), are more challenging to apply and are therefore rarely integrated into research (11).

To bridge the macro and micro levels, we propose the Cockerham theory of health lifestyle that is based on the sociological concept of habitus (12), defined as individuals’ dispositions to see the world and behave in certain ways that are shaped by the interplay between the structural opportunities or barriers the individuals have experienced and the choices they have made over time. Health habitus refers to health-related dispositions that inform patient behavior, including being unwilling to be admitted to a hospital or choosing to leave a hospital against medical advice. The health lifestyle theory posits that exposure to the same structural opportunities or barriers will contribute to making the same choices, and this will contribute to a more durable, harder-to-change health habitus. In turn, a durable habitus begins to operate in part automatically, becoming a habit, and this leads to reproduction of the same health behaviors. Repetition of the same health behavior becomes a health lifestyle (13).

The value of integrating the sociological theory of health lifestyle into our racial-ethnic inequities studies is twofold. First, by exposing the structural origins of patients’ choices, dispositions, and behaviors, this theory effectively bridges the macro and micro levels and reveals the importance of structural interventions to address the social determinants of health (e.g., quality of education, quality of housing, food security, and meaningful employment) to reduce racial inequities in health. Second, by considering the automatic, less conscious features of behavior, this theory offers a more sophisticated understanding of why minoritized patients—whose health habitus is often shaped by lifelong experiences of disrespect and discrimination—react adversely to providers when the latter exercise their authority and discredit patients’ choices through involuntary hospitalization or questioning of patients’ decision-making capacities. This multilayered understanding of patient behavior also avoids the pitfall of implicitly blaming minoritized patients for their health beliefs, lack of health literacy, or distrust of the health care system. In this vein, we have designed training for peer advocates, care managers, and social workers that uses the theory of health lifestyles to promote the skills of mental health providers’ cultural and structural humility (4). This training enables providers to offer targeted support that is informed by the patients' experiences of lifelong structural barriers and restricted choices.

Limitations in the Extant Literature

Finally, as we shift the paradigm of research on health inequities, we must attend to limitations of the extant literature. These limitations include the lack of consistency in how we collect data on race-ethnicity, the limited use of race-ethnicity as a variable in understanding racism, and the lack of a precise definition and operationalization of the structural and social determinants of health. Even in the two articles discussed in this article, race and ethnicity are defined slightly differently, preventing a precise comparison across studies and thus highlighting the value of data harmonization. Future researchers must precisely define the structural and social determinants they elect to include in their studies, justify selection of the specific determinants, and carefully interpret the role of these determinants. For instance, Shea et al. (1) included insurance status and housing (dichotomized as housed or homeless) and referred to these two variables in their conclusion as “multiple social determinants of health,” although the authors acknowledged that education should also have been included. In addition, employment status, income, and history of involvement with the carceral system constitute the minimum variables to include in a study on involuntary commitment, given what we know about racial-ethnic inequities and minoritized patients’ socioeconomic vulnerabilities.

Conclusions

The limitations of the Shea et al. (1) and Garrett et al. (2) articles notwithstanding, we conclude by commending both teams for addressing SREs in the provision of health care and proposing that the racial-ethnic inequities in patients’ involuntary psychiatric commitment and decisional capacity consultations suggest the need to address providers’ interpersonal bias and implicit racism. We look forward to future research that uses theory and data to examine how routine institutional practices in psychiatry and other medical specialties reproduce deeply entrenched structural, and especially racial-ethnic, health inequities.