Black Bostonians are more likely to be sent for involuntary mental health institutionalization by clinicians
November 21, 2024
Black Bostonians are much more likely to have health care providers try to involuntarily hospitalize them amid mental health emergencies, according to a new study out this month.
The process can be initiated by clinicians or police officers if they believe a person is a danger to themselves or others. That prompts an order for local EMS, and Boston police, to transport that individual to a local facility for an evaluation, which can lead to an involuntary commitment of up to three days. More than 40% of the nearly 500 requests that health care workers made in a recent year were for Black patients, even though fewer than a quarter of all Bostonians are Black.
The study’s authors also found that, for every three in four cases, these requests for transport are made by health professionals who haven’t directly evaluated the person. Researchers and advocates say the study identifies discrepancies that should be addressed, and underscores the need for more support before individuals reach a crisis.
In Massachusetts, these court-ordered emergency hospitalizations are allowed under state law, informally referred to as “Section 12s” for the provision that allows them.
“Even when Section 12 apprehensions are done well, they’re still traumatic, right?” said Melissa Morabito, a UMass Lowell professor of criminology and a co-author on the study. “This is still a really bad day for anybody, even if everything goes right. And so I think we want to make sure that involuntary apprehensions and detention are used as little as possible.”
Dr. Kevin Simon, the chief behavioral health officer for the city of Boston who is also a psychiatrist, says the finding isn’t surprising. Multiple studies have found Black people are much more likely than white people to be compulsorily hospitalized.
“We’re recommending more persons who are BIPOC to have these emergency evaluations, emergency transports,” Simon said. “And, again, that necessitates involvement with the police. And the police appropriately have said, ‘Hey, we want to be engaged the right way following the events of 2020.’”
Simon, the study’s lead author, is pointing to an internal change that Boston Police made in 2021 after racial justice protests that followed George Floyd’s killing. Now, when a health care provider calls for someone to be involuntarily evaluated for their mental health, it’s the department’s street outreach unit that is sent to find and bring people in.
The study itself was commissioned by the Boston Police Department with grant funding to look at the year following that change. Boston Police’s communications department didn’t respond to a request for comment.
The impact Section 12s have
Tens of thousands of these involuntary evaluations happen in Massachusetts every year. Advocates say this study provides rare insight into how these tools are applied by health care providers.
Earl Miller, who oversees two Wildflower Alliance respite centers in Holyoke and Springfield, worries about police involvement with mental health crises. After more than a decade with Wildflower Alliance, Miller says he’s never had to call the police for someone to be hospitalized or institutionalized.
“I don’t understand how inviting a person with a gun to that situation is somehow going to de-escalate it in any regard,” he added. “If you understand that people are having some of the worst days of their lives, then it makes sense that they’re not responding in their best way.”
Study co-author Morabito says it shows another one of the “hidden responsibilities” that police shoulder. While the process begins and ends with clinicians, it’s police who are often transporting people to the hospital.
Some advocates believe such institutionalizations should be seen as a violation of someone’s human rights. Miller himself was involuntarily hospitalized when he was younger, which inspired him to enter this line of work.
“It doesn’t make sure that someone’s going to have food, or a house, or anything when they leave that — it just means that they’re going to go to an emergency room,” he said. “If it works the way they say it works, it is going to put someone in a situation where they’re being discharged from a hospital on a new antidepressant.”
The law also specifies that people may be held involuntarily for up to three days if it’s deemed necessary by a psychiatric evaluation at the facility. That clock starts when the person is admitted. And in practice, that means a person may be held indefinitely in the emergency room if there are no free beds. That is explicitly outlined under a 2020 decision from the state’s highest court.
“If people do wind up being taken to the emergency department, there needs to be a time limit and a right to counsel,” said Karen Talley, the director of mental health appeals at the state’s public defenders organization the Committee for Public Counsel Services. “This is basically involuntary detention with no time limit.”
Simon, Boston’s chief behavioral health officer, said the system as it exists is fundamentally unpopular, but he knows police involvement is legally necessary.
“People that have a heart attack, people that are having a panic attack, might very well want to go to the hospital,” Simon said. “The police at times have to be engaged — again, legally. And so us helping explain this and uncover certain things, again, is about: How can we improve the system?”
Points for change
Another finding that struck Morabito: Three-quarters of the requests she and her co-authors reviewed had been submitted by a clinician who had not personally evaluated the person. That means many of these requests are likely being made secondhand — with a clinician calling in from the field, for instance, to someone else who can file the form.
Simon believes that’s because, under the text of the law, only certain licensed professions are allowed to submit that kind of application.
With so few of these Section 12 forms ultimately signed by clinicians who have directly evaluated the person, Simon says that leaves police knowing very little about the situation they’re walking into.
“All they know is it says: Person has a mental health crisis,” he said, embodying the police officer’s point of view. “And now I’m ordered to go apprehend this person and bring them to any number of our regional hospitals.”
Talley says the study underscores the need for alternatives to involuntary institutionalization.
“If there is going to be a Section 12, the personal examination requirement [needs] to be implemented,” she said.
Morabito and Simon say more research is coming soon, and they hope to find out how many of these apprehensions ultimately ended in people being involuntarily institutionalized for a longer time — and why so few forms are being sent in by people who haven’t evaluated the person themselves.