This is the first story in a three-part series about how more people in mental health crisis end up under involuntary commitment (IVC) for treatment and why that’s a problem, as originally reported and published by North Carolina Health News. You can read the second part here, which covers efforts to track the increase in IVCs, while Part 3 covers psychiatric patient transport and why it’s often left to law enforcement.
When Sonia Padial’s grieving son swallowed too many Tylenol, she took him to the hospital for help.
She says her son, Andrew — whose name has been changed to protect his identity — has autism. He struggles to process emotions, especially around loss. He’s an introvert and forms stronger bonds with animals than other people. So when his dog died a week after his 18th birthday last year, Andrew took it harder than most.
The staff at the UNC Hospital Emergency Department in Chapel Hill decided that Andrew needed to be checked into a psychiatric hospital. They began the process to involuntarily commit him, even though Padial said that her son was willing to get treatment and had been cooperative with the medical staff.
Involuntary commitment (IVC) is a 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.” It results in the temporary loss of an individual’s right to make their own health decisions and forces people to have treatment.
When a psychiatric bed became available for Andrew at Holly Hill Hospital in Raleigh, Padial said she and her son were shocked and unprepared for how he would be transported there. Andrew was put in a sheriff’s vehicle with handcuffs on his wrists and shackles on his ankles. A deputy drove him and two other middle-aged male patients — all in restraints — to Raleigh while Padial followed behind.
Starting the IVC process triggers a custody order to be sent to local law enforcement who then pick up and transport the patient to the hospital. Padial said she pleaded with hospital staff to allow her and her family to drive Andrew instead, as she had been allowed to do in the past when he needed inpatient psychiatric care.
Hospital staff apologized, but said, “this is the way it’s done,” Padial recalled.
“I told them that this would be traumatic and was going to make it worse,” she said.
And it did. A few weeks after Andrew came home from the hospital, Padial said he was struggling again. This time he displayed signs of PTSD, including flashbacks, nightmares, panic attacks and withdrawal from others.
The handcuffs dredged up memories of childhood trauma and seclusion, which Padial said occurred during a previous encounter with the medical system.
“And what I did not do was take him back to the hospital,” she said. “I was not going to put him through it again.”
“This is not health care,” she added.
In North Carolina, stories like Andrew’s are becoming more and more common. In the last decade, there’s been a 91% increase in the use of involuntary commitment (IVC) in the state.
Forced psychiatric treatment is on the rise nationally as well. 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.
Everyone interviewed for this story — state health officials, doctors, social workers, policy experts, lawyers and mental health advocates — agreed that involuntary commitment should be used as a very last resort. So why has there been such a huge increase?
It’s complicated. But some common themes emerged when talking with those who work in and around North Carolina’s mental health system.
More patients need a ride
Because of the waning number of community mental health resources, more behavioral health patients are showing up at their local emergency rooms. And they are showing up sicker.
When Angela Strain, head of emergency psychiatry at UNC Hospital, did her residency in Chapel Hill more than a decade ago, most behavioral health patients could be evaluated and admitted to the hospital for inpatient treatment fairly quickly. Today, Strain said that so many more patients show up to the ER for psychiatric help that UNC cannot treat them all on-site. She has to refer them out to other hospitals.
“Unless you have a very solid family unit that’s going to transport a very willing patient, really the only safe way to get someone from one hospital to another hospital is involuntary commitment with a sheriff’s deputy,” Strain said.
In her experience, patients 12 years and older who leave UNC Hospital with an Orange County Sheriff deputy are cuffed. Strain said she often sees the same two officers, who have experience transporting IVC patients, and they use some discretion in regard to restraints.
It’s not uncommon for hospital staff to initiate an involuntary commitment because the patient needs safe, reliable transportation to another facility, according to Mark Botts, a University of North Carolina at Chapel Hill School of Government professor who specializes in mental health law.
Botts has done IVC training with hospital staff around the state for 25 years. During these sessions, some have told him that it’s difficult to arrange transportation for a patient without initiating an involuntary commitment.
“Under the IVC process, law enforcement is obligated to provide the transport,” Botts said. “If it’s voluntary admission, there’s no obligation on any party to transport the patient.”
Why not use ambulances?
If you’re in the emergency room due to a heart attack and you need to be transferred to a special cardiac program, an ambulance will likely take you there. So why doesn’t North Carolina use them to transport mental health patients?
“We provide transportation for all manner of other health crises. But when it comes to behavioral health, we act as if it’s this big mystery of how we move people from one place to another, and that’s absurd,” said Disability Rights NC lawyer Corye Dunn.
“We have a ridiculous number of IVCs,” she said referring to the 91% increase over the last decade. “And a lot of it is that it’s the default setting for the hospitals.”
Most counties reserve ambulances for patients with acute medical needs who may need fluids or oxygen on the way to the hospital, said Carrie Brown, chief medical officer of behavioral health at the state Department of Health and Human Services. “That’s always going to have to be the priority.”
But using law enforcement for involuntary commitment transfers isn’t unique to North Carolina.
“The entire country has reverted to law enforcement for transportation of IVC, which on principle doesn’t make a lot of sense because there’s no crime being committed,” Brown said. “But it’s a very secure way to get people from one point to another safely.”
Recent changes to North Carolina’s IVC law required behavioral health management organizations (LME-MCOs) to work with the counties they cover to create community crisis plans, which include transportation of IVC patients. In short, counties are not required to use law enforcement.
In a new IVC training developed by DHHS, Brown said the department has gone on record saying that involuntary commitment should never be used just because someone needs a ride.
“That’s not what involuntary commitment is about,” she added. “Involuntary commitment must be a last resort. And oftentimes, you can accomplish a voluntary admission, it just takes a little more time.”
Another reason voluntary patients are being involuntarily committed is the misconception that the inpatient psychiatric facilities require it.
Last year when a teenage girl in Chapel Hill was having thoughts of suicide, she agreed to go to the UNC Hospital Emergency Department for help, her father told NC Health News. He recalled doctors telling him and his wife that they could transport their daughter once a psychiatric bed opened up.
“Based on the current evaluation, if receiving facility allows (sic), it would likely be appropriate for parents to transport patient to another hospital given that patient has a good relationship with parents and is seeking help,” the attending psychiatrist wrote in the patient’s records, which the father provided to NC Health News.
The very next line in the patient’s medical chart says a bed became available and commitment papers were filed. The father felt blindsided when he learned his daughter had been involuntarily committed and that a law enforcement officer was there to drive her an hour and a half drive to the next hospital.
At multiple IVC training sessions throughout the state, Botts has heard hospital workers say the psychiatric hospital will not take the patient unless the IVC process has been initiated.
Strain, the UNC Hospital psychiatrist, said the state hospitals — Central Regional, Cherry and Broughton — “won’t accept a patient who is voluntary. Some of the community hospitals would potentially take a patient voluntarily if we had a safe way to transport them there.”
In Mecklenburg County, public defender Bob Ward said he frequently represents clients in involuntary commitment hearings who willingly seek help.
“So I’ve had situations where the doctors don’t like it, the patients don’t like it, and they’re cooperating with treatment, but then they want to go to Broughton to get the help that they need,” he said. “But Broughton will not accept you unless you are committed.”
“You basically have to agree to say, ‘Yes, I’m a danger to myself or others,’ which is pretty discouraging if you think about it,” Ward said.
However, DHHS’s Chief Medical Officer Brown denied this, saying an IVC is not required for admission to the state’s psychiatric hospitals.
Fear of liability
In some ways, involuntary commitment is the safest path of least resistance.
“IVC gives them the ability to streamline this process and guarantee no hiccups from the patient side, even if that might not be entirely necessary,” said Botts, of the UNC School of Government.
There’s a concern that if the patient is transported by family, someone may change their mind on the way to the second hospital, he added. And the patient may not arrive or be admitted safely. IVC is also the path with the lowest risk of liability. There is a common fear that a patient will jump out of a car on the drive from one hospital to another, according to several people interviewed for this article.
Strain said while there are situations where family members of psychiatric patients from UNC Hospital drive them, it’s not the most common route.
“There’s a lot more liability putting someone in a personal vehicle,” Strain said.
At Disability Rights, Dunn said she often hears from health providers with concerns about a patient’s ability to give “informed consent.”
“Which is troubling,” she said. “That’s because they’re worried about liability. But because they’re worried about liability, our clients can’t get the services they need and want without losing their rights, which is a huge disincentive to seeking treatment.”
Criminalizing mental health
Forced treatment under involuntary commitment can deter people from seeking future mental health care. Young people report feeling more depressed and distrustful of the mental-health-care system after being involuntarily committed, according to a 2019 study out of the University of South Florida. USF behavioral health researchers interviewed 30 teens and young adults about their experiences being treated under IVC.
The majority said they would be hesitant to get help next time.
“After the first time I was [involuntarily committed], I felt like if I confided in someone that I was upset, that they would — even if I wasn’t suicidal — that they would [hospitalize] me,” one study participant said. “I felt almost like I was being punished for my feelings. You should be able to feel confident in saying that you’re sad without fearing that you’re gonna be locked up.”
And though there are sheriff’s deputies who work with mental health patients who are experienced and trained in de-escalation techniques, that’s not always the case.
Earlier this year, video surfaced of a teenage boy who was tased and beaten by security guards and a Lincoln County sheriff’s deputy after his mother took him to the hospital for psychiatric help. His mother told WBTV her son had been treated for mental health issues in the past and was already reluctant to go to the hospital that day.
At UNC Hospital, Strain said the default for transportation has been the sheriff. She added UNC is currently working on an alternative transportation plan for their mental health patients.
“We don’t want to be criminalizing mental illness,” Strain said. “Nobody likes the idea of putting someone who is in a psychiatrically fragile state into shackles in a police vehicle. We definitely hear about it from parents when kids have to go. And we hear about it from adult patients who have a history of trauma, with police or having been confined.”
Taking someone’s rights away and tying their wrists and ankles together in the course of mental-health treatment can be an extremely traumatizing experience.
“And to take somebody who’s experienced powerlessness through trauma, and then to remove their power, through involuntary commitment is like compounding trauma on top of trauma,” said Cherene Allen-Caraco, CEO of Promise Resource Network, a peer-run mental health services agency in Charlotte.
Allen-Caraco speaks from experience as a survivor of complex trauma.
“[Involuntary commitment] for me, personally, would be more excruciating, more harmful than anything that could possibly be helpful that came from it,” she said.
Caring for people with complicated mental health issues requires the time and skills to navigate tough situations and conversations, including those about self-harm and suicide, Allen-Caraco said.
“You can’t go to the default of ‘go to the hospital,’” she said. “To do this kind of work well, you need to establish relationship and trust and be comfortable with uncomfortable situations.”
For Padial’s son Andrew, the trauma evoked by the IVC process was so severe that he moved to live with a family member in another state. He feels better now that he’s far away from the place where it all took place, Padial said.
“Though he did nothing wrong, he felt criminalized and humiliated for having a mental illness,” she said. “That experience changed all of our lives. We have a different kid now.”
Padial is working to complete her social work degree and advocates to change the IVC process in North Carolina. And though the last year was tough for Andrew, Padial said he’s attending community college classes and wants to help people like himself someday.
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.
This article includes sources who North Carolina Health News chose to grant a degree of anonymity. They verified the identities and stories of those whose names were changed through interviews and reviews of video and medical records. They changed Sonia Padial’s son’s name to Andrew to protect his identity and blurred his face in the photos. Andrew agreed to the use of his story and photos under these conditions. NC Health News also granted anonymity to a Chapel Hill father and his teenage child due to the sensitive nature of their story.