This is the third 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 first part here, which covers the increase in IVCs in North Carolina, while Part 2 covers efforts to track the data. Part 3 below includes reporting on psychiatric patient transport and why it’s often left to law enforcement.
It’s common for law enforcement officers to respond to people in mental health crises. Desperate family members often call 911 if they believe a loved one is at risk of harming themselves. If a patient expresses suicidal intent, health professionals will sometimes call for the police assistance.
And in North Carolina, sheriffs’ deputies are responsible for transporting psych patients — often in shackles — when they need to go from one hospital to another for forced treatment.
This process, known as involuntary commitment (IVC), is the legal means by 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 as a last resort when a person is an immediate “danger to themselves or others.”
Nonetheless, a group of advocates compiled data from across the state and found that involuntary commitments increased by 91 percent over a decade, far outpacing the state’s population growth. A recent national study also 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.
This is the case, despite the fact that transporting patients in a fragile state of psychiatric crisis in handcuffs by police is widely criticized by mental health advocates. They argue the practice can be traumatic and stigmatizing for patients.
In the wake of protests around policing that rocked the U.S. last summer, the use of law enforcement to respond to mental health crises is being questioned across the country. Advocates are asking if there are other agencies better suited for these roles in the mental health system.
For their part, law enforcement leaders say that transporting IVC patients takes officers off of other duties, sometimes for hours, as they drive across the state to a psychiatric hospital. It can put a strain on smaller departments with fewer resources.
State lawmakers on both sides of the aisle agree that the current practice of shackling mental health patients for transport needs to change. North Carolina counties were given the chance to rethink police transport of psychiatric patients in response to a law that went into effect in 2019. However, the majority of counties opted for minimal to no reform.
The transportation dilemma
As an increasing number of mental health patients wait in emergency rooms, hospitals search the state to find inpatient psychiatric care for them. In 2020, state data shows the average patient waited more than a week in the emergency room for a psychiatric hospital bed. Unfortunately, long waits like these have been common in North Carolina for more than a decade.
As a result, more patients have been involuntarily committed and moved across counties to available beds. Advocates claim that a breakdown in preventive and community mental health services has resulted in more people being committed, which is supposed to be used as a last resort option, not as the standard of care.
In 2018, lawmakers passed Senate Bill 630 which was intended to change North Carolina’s IVC law and reduce the number of people languishing in emergency departments. The new 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. The law went into effect in 2019.
“I think we all agreed that current use of law enforcement to transport patients was suboptimal, and in effect criminalizing the involuntary commitment process,” said Duke University Psychiatry Professor Marvin Swartz, who was part of a work group brought together by the North Carolina Healthcare Association to help write the bill.
“Now in light of rethinking police response to mental health and other kinds of problems, this is really much more obvious,” Swartz explained. He said using sheriffs’ deputies to transport patients is “really only a matter of convenience. It’s not free to transport patients by law enforcement. It’s just cost shifting.”
By law, counties are responsible for providing transportation for IVC patients. It is also legal for a loved one to transport an IVC patient to an available psych bed. However, many times medical institutions are not comfortable with the liability risk of putting a patient in a private vehicle. They want secure transportation.
“Everybody is so risk-averse, they won’t think about the human consequences,” Swartz said. “We were hoping in asking those counties to redo their crisis plans that they would rethink this and look at some of the options.”
Rethinking transportation for IVC patients
As a result of Senate Bill 630, a handful of counties did make changes to the way they transport IVC patients. But of the 60 county transportation plans NC Health News examined, the overwhelming majority will continue only using law enforcement to transport these vulnerable psychiatric patients.
A few counties — such as Mecklenburg, Wake and Forsyth — are using a combination of law enforcement and a private contracted company to transport their mental health patients to a psychiatric bed. Guildford County’s plan included a combination of law enforcement and EMS personnel for transporting psychiatric patients.
A significant number of county plans included efforts to destigmatize law enforcement transports, such as encouraging officers to dress in plain clothes, to use unmarked vehicles and to remind patients that they are not under arrest. Many said they would refrain from handcuffing patients under the age of 10. Several plans encouraged same gender transports, meaning female officers would drive female patients.
However, a couple counties lumped jail inmates and mental health patients together in outlining their transportation plans.
“Senate Bill 630… made it very clear that it is perfectly legal in North Carolina to transport individuals under IVC with entities other than law enforcement,” said Carrie Brown, chief medical officer for behavioral health at the NC Department of Health and Human Services.
Brown noted that the creation of these crisis and transportation plans forced conversations and collaboration between agencies and officials who might not have been communicating regularly, such as LME-MCOs, law enforcement, hospital officials and magistrates.
Officials from Vaya Health, the LME-MCO covering 22 counties in the far western part of the state, said their groups had “lengthy discussions about IVC transportation and the likelihood of options other than law enforcement transport,” according to the agency’s report on community crisis plans.
Right now, law enforcement does almost all IVC transportation in Vaya’s catchment area. A few counties are exploring other options for the future. Vaya officials wrote that sheriffs’ deputies must sometimes drive patients six or more hours to their next hospital bed.
When the patient is eventually discharged, law enforcement is also responsible for their return trip home, Vaya officials wrote.
North Carolina Sheriffs’ Association spokesman Eddie Caldwell said this is an issue for sheriffs across the state.
“We’ve heard stories of people from the far west having to take people down east to Cherry Hospital [in Goldsboro], and people from the east have to take people to the hospital in Morganton,” he said. “The availability of beds is an issue.”
Vaya officials wrote that these long trips contribute to the greatest strain on manpower and cost for law enforcement.
“This responsibility is cited among law enforcement across the focus groups as a duty that could be provided by non-law enforcement entities, if safety and liability issues arising in such situations are adequately addressed,” Vaya officials concluded in their report.
More trainings, health screenings
Under the updated crisis and transportation plans, LME-MCOs pushed counties to require Crisis Intervention Training and/or mental health first aid training for their officers and any personnel from contracted transportation agencies.
CIT is a specialized, weeklong training program that gives law enforcement officers tools to work with people in mental health crises. Officers learn techniques to de-escalate tense situations and appropriate methods of getting people to treatment, rather than jail. Likewise, mental health first aid is a training program that gives people basic skills and strategies to help someone in both crisis and non-crisis situations.
Cardinal Innovations included special offerings of these trainings for magistrates, officers and other transport providers.
When asked how many sheriff’s deputies have completed CIT training, Caldwell said the association doesn’t keep track. He added that while CIT training is important, pulling officers off duty for any kind of training can be challenging.
When Senate Bill 630 went into effect in 2019, it allowed DHHS to create more IVC training programs for the additional health workers who were enabled by the law to do first examinations of mental health patients, such as social workers, physician assistants and certain nurse practitioners. In order to uphold an IVC petition, a health provider must examine the patient and determine that an IVC is necessary.
The new law also included the creation of a screening tool for the first examination to help health providers direct patients to proper care. It includes a flow chart to help determine if the patient’s symptoms are the result of a behavioral health issue, physical issue or a combination of both.
For example, someone with an intellectual or developmental disability might not be able to fully verbalize the pain from a urinary tract infection, constipation or a toothache. This tool and training aims to prevent that patient from being committed to a psychiatric hospital due to an acute health problem.
“One of the major concerns is someone that actually is either having a physical health crisis that is masquerading as a behavioral health crisis or is having both the behavioral health crisis and a physical health crisis simultaneously,” Brown said. “It’s just so crucial that you’re able to identify both of those.”
Lawmakers criticize shackling of patients
Several state lawmakers agreed that more needs to be done to improve the IVC process and detangle the mental health system from the law enforcement.
Rep. Graig Meyer (D-Hillsborough), who is a social worker who has assisted police in de-escalating mental health crises, told NC Health News that he consistently hears from unhappy constituents about IVC transportation.
“Most people are really shocked when they learn that their loved one — especially a minor — is going to be handcuffed for transport,” he said. “And they’re also just generally shocked at how little role parents and family members play once someone has been involuntarily committed.”
Meyer said it’s a tricky situation because sheriffs need to provide security and safety, but he said he understands why patients and their families are frustrated that there isn’t “more individualization.”
“There’s common ground between police and justice advocates and mental health advocates in that none of those groups want police officers to be mental health workers,” Meyer said. “We really need to be thinking about how we respond to community mental health crises and ways to do that only with law enforcement support where absolutely necessary.”
Rep. Verla Insko (D-Chapel Hill) said she thinks shackling young mental health patients should be illegal.
“The idea of putting a 5-year-old in shackles is just obnoxious,” Insko said, adding that she’s found nothing in the law that requires shackling.
The problem of rising psychiatric hospitalization comes back to a lack of community resources and a shortage of providers and insurance options, she said. Insko added that North Carolina has never properly invested in community mental health.
“If your first step breaks down, then you are going to use your second or third step,” Insko said. “We’re hurting ourselves putting people in institutions and having them go through these traumatic experiences. It makes them worse, not better. And so we end up with more and more people in prison, and we end up with more and more people in institutions.”
Rep. Marcia Morey (D-Durham), a former District Court judge, said she’s presided over many IVC hearings where patients are in full shackles in her courtroom.
“I think we need to keep safety in mind, but there’s often ways to do this without the extraordinary means of shackling,” Morey said during a discussion on involuntary commitment during the annual Legislative Breakfast on Mental Health in January. (NC Health News was a media sponsor for this event and NC Health News editor Rose Hoban moderated a legislative panel during the event.)
Morey said the health system should look into the least restrictive way for people to move through an involuntary commitment, while transporting psychiatric patients as little as possible. The COVID-19 pandemic has shown society just how much can be accomplished virtually, she said.
“If you’ve never either been in handcuffs or had a family member in handcuffs, that’s traumatizing for a person that is completely without any type of mental health issues,” said Rep. Robert Reives (D-Sanford) during the breakfast.
If specialized, trained teams were used instead of law enforcement, there would be less need for shackling of mental health patients, he said.
The issues around mental health crisis care have only worsened during the pandemic, Rep. Carla Cunningham (D-Charlotte) added.
“During COVID, we’ve had people laying on the floors within triage facilities. We’ve had them lined up outside waiting to get in because they need emergency health services for a mental health issue that’s going on,” she said. “We’re in a crisis, but we’ve got to invest in it going forward because we were already in crisis before.”
Sen. Jim Burgin (R-Angiers) told others at the breakfast how troubled he was to receive a call from a constituent whose child with a mental health issue had been handcuffed to a bed for three days.
“We don’t need to do things like that,” he said. “Taking someone who’s having a mental episode and restraining them is never good.”
Rep. Pat Hurley (R-Asheboro) suggested the formation of a legislative mental health caucus to examine problems such as IVC transportations. Those watching the virtual discussion on Zoom applauded her proposal.
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.