Advocates found the state had a big problem, but because no one was counting, no one was aware of how many psychiatric patients were being treated against their will. This is the second story in a series about how more people in mental health crisis end up under involuntary commitment for treatment and why that’s a problem, as originally reported and published by North Carolina Health News. Read the first part here.
Robert Ward has been representing clients with mental health issues when they come before a judge in involuntary commitment hearings for almost a decade. And in recent years, he noticed his caseload increasing in Mecklenburg County.
Ward, the assistant public defender, asked his local clerk of court’s office to share the number of involuntary commitment (IVC) petitions, the legal process in which a layperson or medical professional asks a judge to order mental health or substance use treatment for an individual against their will.
It’s supposed to be used when a person is an immediate “danger to themselves or others.” Involuntary commitments result in forced psychiatric treatment.
In Mecklenburg County, Ward found that these petitions more than doubled over the last decade, even accounting for population growth, from 6,103 a year to 14,328. And medical facilities asked for the vast majority of the petitions in his county. Ward had been working with court programs that divert people with psychiatric issues from the criminal justice system into treatment. Now, after 20 years, he wanted to help advocate for those with psychiatric issues in civil court before they end up on the criminal side.
He was curious if what he saw in Mecklenburg reflected a statewide trend, but he couldn’t find any data on involuntary commitments in North Carolina.
“Which led me to question, ‘Is anyone minding the store on this?’” Ward said. “And of course, you find out that nobody is tracking it.”
“You cannot manage what you don’t measure,” he added.
They discovered that forced psychiatric treatment under involuntary commitment increased by 91% over a decade, far outpacing the state’s population growth.
This mirrors national trends. A recent study found that the rate of involuntary commitment is climbing three times faster than the population growth in 25 states for which IVC data is available.
The study authors found no data for North Carolina.
Hunting down data, county by county
It took several months to track down the total number of involuntary commitments — coded as Special Proceedings Confidential — because each county clerk’s office records their own total.
When the counties submit their IVC petition numbers to the NC Administrative Office of the Courts, the state lumps them together with other special proceedings. At first, Ward said he talked to several people at the state office who said they couldn’t give him the numbers.
He decided to contact all 100 counties to gather the data. Ward enlisted the help of John Weddell, a UNC Charlotte social work student interning with Promise Resource Network.
“What I started doing, which was insane, was calling every single county clerk’s office and trying to find the admin person who files all the special proceedings,” Weddell said.
Getting the totals from each county took multiple calls and emails.
“This is going to take me a lifetime,” he thought.
Meanwhile, every county clerk told Weddell that they report their IVC numbers separately from the larger total of special proceedings when they submit their numbers to the state.
After slogging through calls to 25 counties, Weddell realized he could simply go back to the Administrative Office of the Courts. He continued calling until he found the right office, the one that collected the totals directly from the counties. Finally, that office was able to give Weddell monthly IVC totals from each county for 2009 through 2018.
Occasionally, Weddell found some gaps in the state office’s numbers. Calling those respective counties helped him to fill in the blanks.
“It is all being reported to the AOC [Administrative Office of the Courts], but the versions they report back out don’t highlight the IVC numbers,” he said. This means the counties actually do track involuntary commitments, but then the state groups them in with other numbers and does not report them separately to other agencies or the public. The result: The larger problem of IVCs gets obscured.
The N.C. Department of Health and Human Services doesn’t collect comprehensive data on involuntary commitments either. There’s some limited data reported by inpatient psychiatric facilities to DHHS, said Carrie Brown, chief medical officer of behavioral health at DHHS. But that data doesn’t represent the total number of IVC petitions, as those numbers are kept by the counties, she said.
“The data is very siloed,” Brown added.
Limitations to the data
The involuntary commitment data tracked by the county clerks of court only represents a petition, those requests to the court to hold someone for mandatory mental health treatment. A legal involuntary commitment must then be upheld by a judge within seven days after the petition.
The data doesn’t tell us what ultimately happened to that patient.
The data also doesn’t reveal how far each petition for involuntary commitment went. Was the patient picked up by law enforcement? Did the first exam by a health care worker confirm the need for treatment? Did the patient go to an inpatient facility or were they released?
There’s no data to answer these questions, either.
“Each of those numbers represents a certain amount of time that a human being is under a court order or a coerced treatment,” Ward said. Additionally, these numbers do not equate to people, but to commitment episodes, he clarified.
Some people cycle in and out of the hospital, Ward explained. He said he’s represented several clients more than once. While there’s a small percentage of commitment petitions that are denied, he said the majority end in commitment orders.
It’s also unclear how much money the state spends on the increasing number of involuntary commitments since no one is tracking them.
The average cost of inpatient psychiatric treatment in North Carolina is $2,234 a day, according to Kaiser Family Foundation’s 2018 estimates.
“It is difficult to calculate the cost, as the length of stay varies tremendously,” said Alliance Health spokesperson Doug Fuller. “Some individuals may be hospitalized for as little as three days and some individuals in state care may be under IVC for years.”
The average inpatient rate for Alliance, which manages behavioral health care for Durham, Wake, Cumberland and Johnston counties, is $500 a day, Fuller said.
Because sheriff’s deputies transport the majority of patients who are committed, there is a cost to their departments as well. In smaller counties with fewer staff, this could mean taking an officer off regular duty to transport a patient across the state.
The Mecklenburg County Sheriff’s Office (MCSO) reports it spent about $28,000 on transportation of IVC patients in fiscal year 2020. While the MCSO has a $121 million budget, many smaller counties spend larger proportions of their annual budgets on transportation, something that’s a concern for the North Carolina Sheriffs’ Association.
Earlier this year, Ward said he represented two clients back-to-back, one spent 200 days at a state hospital and the other 160 days at a community facility. He said the combined cost to hospitalize these two patients was $900,000.
“As I understand it from the treating medical professionals, such stays were unnecessary and counter therapeutic,” Ward said. But, he noted “they were necessary because of the lack of resources or an inability to provide for the need on a timely basis or some combination of both.
“That’s part of the problem, we don’t seem to have a way to know.”
There’s a cost to patients as well, many of whom say treatment under involuntary commitment is a traumatizing experience.
“The human toll, the financial toll, the resource toll … this is painting a picture and it’s not a good one,” said Cherene Allen-Caraco, CEO of Promise Resource Network, who has been critical of the many and disjointed state efforts to reform the state’s mental health system over the past two decades.
“I think what the IVC rates show us is a complete dismantling of community mental health, and that we have created so many barriers to access to things that are meaningful,” she said.
NCHA, which represents the interests of the state’s hospitals, gathered a work group of those involved in the IVC process to help shape and write the legislation.
Karim noted the involuntary commitment process involves multiple systems — health-care providers, hospitals, courts, law enforcement — and there are multiple data sources and data gets reported to different entities.
“It’s part of what makes involuntary commitment data complicated,” she said.
Over the course of the work group meetings to revise the state’s IVC laws several ideas were vetted, but they didn’t all make it into the final bill, Senate Bill 630.
More data collection on the IVC process was one that didn’t make the cut, according to Mark Botts, a UNC Chapel Hill School of Government professor who specializes in mental health law.
“Language was being considered for hospitals to gather and report IVC data,” Botts said. “During the meetings, some hospitals opposed more robust data collection and reporting requirements.”
Ultimately, Botts said that the data collection requirement was left out of the bill due to the opposition.
Karim didn’t comment specifically on the issue Botts brought up, but she did say there was discussion around whether or not to include a reporting requirement for law enforcement on their use of restraints for patients transported under IVC.
She said the health providers receiving these patients have expressed concern about marks on patients’ wrists, likely left by handcuffs, and wanted a way to better identify the source of them.
Botts said there are many specific data points around that he believes would be helpful in gaining a better understanding of what’s happening with involuntary commitment in the state. He listed the types of questions he’d like to see answered:
- How many patients brought to the hospital under a custody order move to the next step and how many are released?
- How many IVC patients were held because there was no inpatient bed available, and how long were they held?
- How many couldn’t move on to another facility because of another medical issue?
- How many came to the hospital on a custody order that didn’t meet commitment criteria after the first exam?
“This data would be helpful for making informed policy decisions moving forward,” Botts added.
Senate Bill 630 was just the start of reform to the state’s IVC laws, Karim said.
“There are still gaps,” she said. “This is not a ‘one and done’ reform. We want to build on the momentum and energy of Senate Bill 630.”
This article originally appeared at North Carolina Health News, an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina.