Report Makes Troubling Findings About Involuntary Commitment in NC
Disability Rights NC makes recommendations for fixing what's clearly a broken system
Disability Rights NC (DRNC) published a damning report this week examining North Carolina’s involuntary commitment (IVC) process — and offers recommendations on how to fix it.
”North Carolina’s IVC process is marked by systemic overuse, misuse and harm,” read a press release from the nonprofit legal agency that advocates for those with disabilities, “resulting in tens of thousands of children and adults … stuck in a civil process intended to be the last resort but that has become ‘the easy way out.’”
The agency collected data over more than a year while investigating NC’s IVC procedure, which DRNC defined as “a civil, legal process of detaining and hospitalizing a person against their will based on an allegation of severe mental illness.”
Using the organization’s federally mandated monitoring authority, DRNC staff monitored 10 emergency departments (EDs) across the state and collected interviews from people who were subjected to IVC and their families. The report’s authors also interviewed hospital officials, mental health advocates and legal scholars.
“We urgently need changes to make people stop and acknowledge the potential harms of IVC before rushing into it,” said Virginia Knowlton Marcus, CEO of DRNC. “People and families are needlessly suffering. Our systems are needlessly suffering. Costs are soaring without positive results. We must act swiftly to ensure people can get the help they need when and where they need it, and not wind up subjected to forced hospitalization in expensive, ill-equipped facilities.”
Report calls for more training
The involuntary commitment process in NC begins when a person petitions the local magistrate to have an individual committed to an inpatient facility to be treated for mental illness or substance abuse treatment. If the magistrate “reasonably believes” that the facts in the petition are true and the subject (called a “respondent”) is mentally ill, dangerous and in need of treatment, the magistrate will sign an order for IVC and custody, the report said.
It is noted in the report that the petitioner does not have to have first-hand knowledge of the facts alleged.
Law enforcement or another designated transporter then brings the respondent to a hospital or other facility for a first examination, which must happen within 24 hours of the respondent’s arrival.
DRNC discovered five key findings in NC’s IVC process: a lack of due process, traumatic detention, harm to families and communities, systemic failures, and misuse.
The report also emphasized that the magistrates who act as the deciding factor on whether or not a patient is detained involuntarily are not required to be lawyers or even undergo specialized training about the IVC process in North Carolina.
DRNC recommends that legislators amend state law to require specialized training in the IVC process and its collateral costs and train magistrates on the trauma that IVC causes and the benefits of NC DHHS’s crisis services information, among other recommendations.
DRNC found that under NC law, due process is denied in hospital EDs.
The custody order requiring a person to be examined at the ED lasts for seven days. If the order is not renewed, the person must be discharged. If the order is renewed, it could lead to successive custody orders, each one for a seven-day period, according to Mark Botts, associate professor of public law and government at UNC School of Government.
Successive custody orders create a loophole in the requirement to provide a respondent with legal representation and hearing within 10 days of being taken into custody, potentially holding respondents for weeks in “psychiatric limbo.”
In that time, respondents do not receive treatment and are held involuntarily.
No data is kept on successive seven-day petitions so there is no way of knowing how often or where this is happening.
DRNC found that respondents experience traumatic detentions.
People, including young children, can be subjected to strip searches, physical restraints, forced medication, handcuffs and shackles while being transported to a facility.
”While the civil commitment process is not a criminal process, it has all the hallmarks of a criminal process,” the report said.
“I didn’t get treatment, I just got locked up for six days,” respondent Tracy Boggiano said. “If anything, I came out worse than when I went in.”
Read more: My Journey Through the Mental Health Care System Showed Me Its Failings (2024)
Boggiano described the crisis facility’s environment as chaotic. There were fights and yelling and her assigned psychiatrist stripped her of most of her medications.
Because of her traumatic experience, Boggiano learned what words to use and not use so she never gets involuntarily committed again, something DRNC reported hearing from nearly every person with lived experience they interviewed.
DRNC found the IVC process causes harm to families and communities.
Botts said parents or legal guardians of minors sometimes take their child to an ED seeking voluntary care only to be met with IVC petitions.
“Upon invoking the IVC process, some hospital EDs stop consulting and sharing information with the parents, even though the parents retain a statutory right of access to their child’s health care information,” Botts said in the report.
“Parents will be at the ED one day and return the next day to visit their child, only to find their child is no longer there, having been transported several counties away to a psychiatric inpatient facility.”
Read more: Involuntary Commitments on the Rise Despite Warnings from Experts (2020)
The IVC process also causes job loss and financial hardships, with the cost for uninsured and underinsured people averaging over $2,000 per day. Some folks lose their jobs after they’re held for multiple days, unable to attend work while they are under involuntary mental health treatment.
The cost stretches resources, too. Law enforcement officers across the state regularly spend hours transporting people to hospital beds and picking them up after they’re discharged, becoming the default IVC transportation in lieu of available community mental health services.
DRNC found a lack of data tracking the IVC process and misuse of it in general.
Expanding on the lack of data surrounding successive custody orders, the IVC process lacks adequate data tracking and evaluation, the DRNC’s report found.
Because NC collects so little data about the process, identifying where adjustments to law or policy should be made to prevent wrongful, wasteful or inefficient actions is difficult.
“What’s not measured cannot be managed,” retired Mecklenburg County public defender and mental health advocate Bob Ward said.
In the data that is reported, DRNC found that 63% of the tens of thousands of petitions for IVC over the past six years did not result in an order for involuntary commitment, indicating inappropriate use of the process.
Rusty Miles, director of the ED at Carteret Health Care in Morehead City, has seen people use IVC “to make a statement to their partner that ‘I can do this to you,’” or for people who have overused alcohol.
The report said that, nearly universally, administrators report that some nursing homes or assisted living facilities regularly take out IVC paper to “dump” patients with dementia at their ED, as the hospitals are forced to take them in under federal law.
Children are also “dumped” in EDs by frustrated family members and caregivers who can’t obtain appropriate services, using it as a legal lever for finding care for the child.
DRNC said this misuse is utilized rather than addressing mental health needs compassionately and effectively.
“In my opinion, the IVC process is broken,” Miles said. “It should only be used if the person is a safety risk for harm to self or others.”
DRNC’s recommendations for change
After monitoring how the involuntary commitment process plays out in NC’s institutions for over a year, DRNC concocted five recommendations to address the current crisis and rebuild a more humane and responsive process focused on care and healing while reducing abuse and waste.
The five key recommendations are:
- End misuse and overuse of IVC
- Reduce harm during transport
- Reduce harm in facilities and courts
- Build out evidence-based alternatives
- Collect and share critical data
“Reform will require a determined effort from various stakeholders, including state and local elected officials; policy makers within NC’s Department of Health and Human Services; health care provider agencies and hospitals; among others — and must include and center people with lived experience in the creation of solutions,” DRNC’s press release said.
DRNC emphasizes that the answer to this crisis isn’t to increase the number of psychiatric hospital beds, but to ensure children and adults have access to the mental health services and treatment they need when and where they need it.
“Simply put, NC needs robust mental health services in our communities,” the report reads. “We must prevent crises from happening to begin with. We must keep people healthy, in their homes, in their communities, where they can thrive and be successful.”
Read the full report, titled “Involuntary Commitment in NC: Overused, Misused, and Harmful,” here.
