Decarceration through Coercion?: An Ethnographic Examination of Involuntary Outpatient Commitment and the Criminal Justice System

Background and Purpose: Involuntary outpatient commitment (OPC) is framed by advocates as a method to decarcerate populations with serious mental illness (SMI). OPC uses coercion, including court-mandates, to compel full participation in community-based psychiatric services. Despite advocacy for OPC, little research has focused on the actual processes by which OPC interfaces with the criminal justice system. Further, while mass incarceration has and continues to pose serious consequences for people with SMI and their communities, there are ethical considerations to the use of coercion in mental health services. This includes whether coercion is harmful to therapeutic processes and, more broadly, whether OPC unfairly targets communities who would benefit from more voluntary services and resources in the first place.

To develop a better understanding of the role OPC plays in decarcerating people with SMI, this study examines both the decarceral OPC processes (e.g., treatment) and the various interactions clients have with the criminal justice system. In doing so, we aim to further evaluate these ethical dilemmas and provide direction in the broader pursuit for smart decarceration and ethical systems of care.

Methods: The primary methods were ethnographic observations (<1000 hours), including semi-structured interviews, and a quantitative analysis of administrative datasets. Data was collected as a part of a contracted quality improvement evaluation of Los Angeles County’s OPC program. A team of ethnographers conducted participant-observations of community outreach services, court hearings, and treatment delivery beginning in October 2016. Semi-structured interviews were conducted with 24 outreach workers and treatment providers, 20 clients, and 12 family members.

For the analysis, thematic codes were developed in an interdisciplinary research team to capture the emergent processes and themes in the notes. All coded data related to incarceration and decarceration were then extracted. Next, data were compared to identify prominent patterns in relation to people’s perceptions of and experience with OPC and incarceration.

Results: OPC helped to decarcerate prisoners with mental illness, though 34% of participants still had contact with law enforcement and 28% were incarcerated during treatment. Further, OPC providers theorized that its services reduce disruptive behaviors to make clients less vulnerable to arrest and that this justified the use of coercion. Lastly, coercion regularly took the form of persuasion, such as leveraging resources and rapport-building, to facilitate participation in services. To this end, OPC provided a less restrictive alternative to incarceration. However, OPC implementation was problematic. OPC lacks specific mechanisms to address violence perpetration and victimization. Further, as treatment did not automatically include housing, clients were often placed into neighborhoods with few services, an abundance of open-air drug markets, and racialized policing practices. Our observations highlight specific examples to demonstrate how these factors can facilitate continued incarceration for OPC clients.

Conclusions and Implications: There is an urgent need to develop decarceration methods for serious mental illness. While OPC services may be ethically preferable to incarceration, without proper adjacent systems of support (such as housing), it risks leaving people with SMI still vulnerable to adverse outcomes.