By Taylor Knopf
Key takeaways:
- NC’s involuntary commitment system faces scrutiny for leaning on emergency rooms, law enforcement and court orders in mental health crises.
- Families and advocates say patients and caregivers are left confused, sidelined and wary of seeking help again.
- State leaders are pursuing reforms to cut unnecessary commitments, expand voluntary treatment and improve follow-up care.
Earlier this month, Jacob Dehart’s daughter was in the emergency room in Winston-Salem after she attempted to harm herself. The family was asking for help.
Days later, when it was time to admit his daughter to a psychiatric hospital, a uniformed law enforcement officer transported the vulnerable teen in a marked car. In between, Dehart said he and his child’s mother were shut out of the decision-making process.
“From the beginning, I wanted everything to be voluntary and cooperative and let us have kind of a say in it,” he said. “But we feel like we were ignored.”
Dehart told NC Health News that hospital staff kept telling him his daughter would be “transferred,” a word he took to mean an ordinary move between hospitals — not the start of an involuntary psychiatric commitment. He said the social workers in the emergency room seemed to be reading from a script, and any question he asked was treated as interrupting.
Trying to understand their options, Dehart contacted Mark Botts, an associate professor at the UNC School of Government and one of the state’s legal experts on involuntary psychiatric commitment.
Botts trains health providers and magistrates across North Carolina around what should happen when someone is considered a danger to themselves or to others. In that circumstance, state law allows for an involuntary commitment custody order, which temporarily suspends certain rights while the person receives mental health treatment.
From the emergency room, Dehart put Botts on speakerphone with a hospital social worker. Botts explained that because the patient’s parents were consenting to inpatient treatment, the hospital could pursue voluntary admission instead.
“They cannot treat her without the parents’ consent for treatment, and consent for treatment to be truly informed requires the decision maker to have information,” Botts later told NC Health News.
“It’s maddening,” Botts said. “Imagine if it was not a mental health crisis, but some other physical health emergency — they wouldn’t push the parents aside like this.”
For a moment, Dehart said he felt hopeful that everyone was on the same page and they could move forward with voluntary treatment, but it fell apart the next day when an officer arrived at the hospital to transport his daughter to a psychiatric facility.
This type of transport — often shackled at the wrists while sitting in the back of a sheriff’s vehicle — is a standard practice that many object to, including law enforcement agencies themselves, because it’s traumatizing to patients and puts strain on their departments.
With his daughter in tears, Dehart said he talked the officer out of using handcuffs on her.
“The transfer itself with the police, that was hard for everybody,” Dehart said. “I mean, honestly, she’s going to need counseling for that before we can address what the issue was.”
Even with one of the state’s leading legal experts explaining their options in real time, Dehart’s family couldn’t change the outcome. This family’s experience is not unusual. Over the past several years, NC Health News has fielded dozens of messages and calls from families across North Carolina describing similar experiences.
NC Health News’ guide: What happens when you take someone in crisis to an E.R.? This guide addresses many frequently asked questions about involuntary commitment and psychiatric hospitalization.
On Wednesday, Sept. 30, more than two dozen people who know the state’s psychiatric crisis system from different perspectives will meet to discuss problems in the state’s mental health crisis system and ideas for reforming the involuntary commitment process. The meetings will be livestreamed.
A familiar story
The committee, convened by the N.C. Department of Health and Human Services, includes attorneys, law enforcement personnel, crisis providers, juvenile justice officials, hospital administrators, judges, lawmakers and peer support specialists.
Earlier this month during the group’s inaugural gathering, Kelly Crosbie, director of mental health for NC DHHS, said she gets a call from a family like Dehart’s at least twice a month.
“The story is always the same,” Crosbie said. “It’s either their minor child or adult child that they voluntarily took to the hospital, and then they were [involuntarily committed],” Crosbie said. “And I don’t understand that dynamic. I’m not hospital-blaming. I have no idea why. But they also don’t understand why. They’re so baffled, and it’s very hard to tell them I can’t do anything about that.”
Committee member Robert Broughton, an attorney with the N.C. Department of Justice, offered two possible explanations, speaking from what he’s seen. In one, a child is brought in for an acute psychiatric emergency, the hospital lays out a treatment plan, and parents get “cold feet,” creating a disconnect between the provider and the family about what’s needed. In the other, the hospital staff want secure patient transportation to the next hospital and don’t want to risk someone stopping along the way or changing their minds.
Under both scenarios, he explained, an involuntary commitment order is usually the result.
Many families are surprised to learn that under North Carolina law, the involuntary commitment process usurps the rights of a parent or guardian to make some health decisions for their child, particularly around where the patient will receive treatment. Crosbie took issue with this.
“They don’t seem to have that ability to say ‘Fine, but not there,’” she said. That part of the law needs to be changed, Crosbie said, while gesturing to the handful of lawmakers in the room.
Cherene Caraco, director of Promise Resource Network, a mental health agency based in Charlotte and run by people who’ve experienced the mental health issues firsthand, described another factor at play: fear of liability. Dehart said he believes that fear — in part — drove his own experience at the hospital emergency room.
more coverage of mental health
Caraco told the committee there is a widespread fear that if the hospital releases someone to outpatient care and something bad happens, that they will be sued.
These are just a few of the many issues within a larger, more complex mental health system that this committee was formed to address.
A mandate for change
Involuntary commitment reform has become a bigger priority in North Carolina over the past year.
This committee was formed in response to Gov. Josh Stein’s executive order on mental health, which orders interagency cooperation to strengthen how law enforcement and mental health agencies can coordinate. The other impetus was a law passed by the General Assembly this summer that directs DHHS to organize a work group to recommend reforms to the involuntary commitment process and work toward solutions to stop people with severe mental illness from cycling in and out of jails and hospitals.
“We know we cannot fix it all,” Crosbie told the committee at its first meeting. “We want to come up with good recommendations and a well-functioning mental health crisis system so that we can have a dramatic reduction in involuntary commitments. In some ways, we lead the nation on involuntary commitments.”
Requests for involuntary commitments have been on the rise in North Carolina for more than a decade, increasing by at least 96 percent, according to data collected and reported by NC Health News, rising from about 54,000 in 2011 to more than 106,000 in 2021.
The committee, co-chaired by Crosbie and Sherry Hunter, deputy secretary for the N.C. Department of Public Safety, will meet monthly through the end of the year and deliver final recommendations to the General Assembly early next year.
Members have already flagged several problem areas:
- an overreliance on involuntary commitment as the “default front door to care,”
- an overreliance on emergency departments and law enforcement to manage mental health crises,
- weak follow-up care and community connections after someone is discharged from a psychiatric facility.
Experiences like Dehart’s carry an additional risk in that families who feel shut down or overridden by the system sometimes hesitate to ask for help during a future crisis. For Dehart, that’s part of why he’s sharing his experience.
“We want to use this for some kind of good,” he said.
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