By Taylor Knopf
When someone is having a mental health crisis — whether they’re thinking about suicide, acting erratically or experiencing hallucinations — they frequently end up in a hospital emergency department, mostly because there are few places for them to go.
If a medical provider determines that the patient is a danger to themselves or to those around them, it’s standard practice to petition a judge for an involuntary commitment order.
These types of orders typically bring law enforcement officers into the process.
Involuntary commitments are supposed to be a last resort to mandate psychiatric care at an inpatient facility for a specified amount of time. These experiences are often emotional for the patient and their loved ones. In that vulnerable moment, a uniformed officer arrives at the emergency department to drive the patient — handcuffed in a patrol car or an inmate transfer van — to an inpatient psychiatric facility that has an available bed.
It’s a practice that many patients find traumatizing. But it will soon be changing in North Carolina.
One mother in Wilmington recounted to NC Health News her deep distress watching her 25-year-old daughter shuffle out of the hospital in handcuffs and ankle shackles attached to a chain around her waist as two officers led her to an inmate transfer van headed for another hospital. Another committed patient believed he’d been arrested and was going to jail after officers handcuffed him and drove him away from an emergency room in Chapel Hill. Parents have pleaded with medical staff to let them transport their children between facilities — some as young as 11 — but were told no.
All this occurs even as North Carolina sheriffs say they don’t want to be the ones moving patients, arguing that it should be done by mental health workers. They also say driving patients across the state to available hospital beds strains their resources, diverting sheriffs’ deputies from responding to crimes and other emergencies, sometimes for hours at a time.
For years, NC Health News has received scores of calls and emails from patients and their families shocked and traumatized by the presence of law enforcement and use of handcuffs in the course of mental health treatment. State officials and lawmakers receive the same frustrated calls from their constituents and have condemned this further stigmatization of mental health. While there have been some legislative efforts to soften the response to people experiencing mental health crises, those largely fizzled out — until now.
Out of North Carolina’s federal sign-on bonus for expanding Medicaid, state lawmakers allocated $835 million for behavioral health needs in their 2023 budget, including $20 million for a non-law-enforcement transportation pilot program for mental health patients under involuntary commitment. In December 2024, the state Department of Health and Human Services released a request for proposals from qualified transportation vendors with a plan to operate the pilot in two regions of the state.
The existing system is “the antithesis of care, and it puts them on the backtrack to recovery,” former Secretary of Health and Human Services Kody Kinsley told NC Health News. “We have been eagerly and desperately trying to decouple these two systems, as are other states, and so we’re excited for this pilot.”
Rising number of police transports
Law enforcement transports of mental health patients are happening more frequently in North Carolina. Involuntary commitment petitions increased by at least 97 percent from 2011 to 2021, according to data collected and analyzed by NC Health News. As community mental health resources dwindled and the state’s growing population needed support, more patients started showing up in crisis at emergency rooms.
In North Carolina, involuntary commitments are sometimes ordered even if a patient comes to the hospital voluntarily or if they or their guardian agrees to inpatient treatment. The reasons for this vary — from the need for a safe transportation option to the incorrect perception that a patient needs to be committed to be treated in a psychiatric facility.
Counties are responsible for the transportation of patients under involuntary commitment, according to state law, and traditionally this role has fallen to law enforcement. Involuntary commitment petitions often trigger a transportation request to law enforcement if the patient needs to be picked up in the community and taken to a hospital for an evaluation and/or transported from a hospital emergency department to an inpatient psychiatric facility, even if it’s across the state.
In 2018, North Carolina lawmakers revised the state’s mental health laws to allow more flexibility, including alternative means of transportation for patients. County leaders were told to submit their transportation plans for these patients to the state health department. In 2021, NC Health News reviewed an incomplete number of available plans provided by the state health department and found the majority of counties opted for minimal to no changes to the practice of using police or sheriff’s deputies.
Law enforcement transports are the default for patients under involuntary commitment across the United States. In October, the Wilson Center for Science and Justice at Duke Law released a report that found that 43 states have some allowance for non-law-enforcement transportation of a committed patient, including North Carolina. However, the study authors wrote, most states largely rely on law enforcement because they haven’t established or invested in alternative models.
The Duke Law report evaluated responses to people in crisis nationwide and recommended that policymakers remove law enforcement from all mental health interventions as much as possible.
“Not only does law enforcement involvement blur the lines between treatment and criminalization of mental illness, people with serious mental illness are also overrepresented in law enforcement use-of-force encounters and law enforcement-related injuries,” the report authors wrote. “People with serious mental illness are over eleven times more likely to experience law enforcement use of force and over ten times more likely to be injured in law enforcement interactions compared to other individuals.”
Wrong job for law enforcement
Law enforcement officers across the U.S. have said they shouldn’t be responsible for transporting mental health patients. The North Carolina Sheriffs Association said that role should be turned over to mental health professionals.
N.C. sheriffs say that transporting mental health patients takes officers off of other duties, sometimes for hours or entire shifts, as they drive across the state to a psychiatric hospital. It can put a strain on smaller departments with fewer resources.
A national survey of 355 sheriffs’ offices and police departments found that an average of 10 percent of the agencies’ total budget was spent transporting patients under involuntary commitment, according to a 2017 report by the Treatment Advocacy Center. Based on the survey responses, the report estimated that law enforcement agencies spent $918 million nationwide transporting committed patients that year. The survey respondents estimated they spent 165,295 hours, which equated to 21 percent of total staff time, responding to and transporting mental health patients.
Additionally, officers often don’t have the training or tools to respond to mental health calls. Their presence alone — with marked vehicles, flashing lights, uniforms and firearms — often escalates a situation. A study that conducted in-depth interviews with 40 young people who had been involuntarily committed in Florida found that the majority had negative experiences with law enforcement.
“Major themes characterizing negative encounters were the framing of distress as criminal or of intervention as disciplinary rather than therapeutic, perceived aggression and callousness from police officers, and poor communication,” the study authors wrote in 2021.
The study quoted several participants, including a Latino college-aged male who said: “The sheriff’s officer […] was kind of a jerk. […] excuse my language, he’s like, ‘Don’t touch my [expletive] you [expletive] retard.’ Then, sitting in the car with that guy for an hour and 15 minutes on the drive . . . he wouldn’t shut up about how much of a piece of [expletive] he thought that people like me were. And criminals, and you know . . . he equated me with criminals. I was numb at that point.”
A multi-racial female college-aged participant said the male officer who transported her said: “Don’t mess around with me or I’ll show you who’s boss.”
“Very aggressive for the situation,” she told the study authors. “It was really scary.”
Negative policing interactions can cause post-traumatic stress disorder, particularly for a patient already struggling with their mental health and in distress. After a traumatic mental health intervention, patients often say they are hesitant to reach out for help again.
What are some alternatives?
North Carolina is inviting companies to come forward with proposals for how to transport mental health patients differently. Kinsley said the Department of Health and Human Services has a high bar for this contract and will be paying a premium to get a transportation service that is high quality.
“We’re not just going to award it to whoever comes forward. Part of the reason why we have been moving slower on this than I would have liked is because we haven’t been able to find a perfect prototype in the nation,” Kinsley said when the proposal was released in December. “I have not seen another state really figure this out perfectly yet. There are some contractor companies that are doing this in a way that looks a little too law enforcement-adjacent to me.
“We really want to center this on: What does real care and support in transport with the right resources look like?” he added.
There are some examples of mental health crisis response units in other states that respond to 911 calls related to mental illness, homelessness and substance use. Among those are the CAHOOTs program in Oregon and, closer to home, the HEART program in Durham. Rarely have teams in either state needed to call for law enforcement backup. The Duke Law report pointed to both programs as examples of non-law-enforcement groups that are able to respond safely to people experiencing mental health distress.
“When determined to be safe, alternatives may include family, friends, medical providers, mental health professionals, ambulance services, and/or other authorized providers,” the study authors wrote.
They cautioned, however, that mobile crisis units, which are therapeutic teams that respond to people experiencing crises in the community, “in particular seem hesitant to be tied to the [involuntary commitment] process for fear of fostering mistrust.”
In North Carolina, one seemingly unknown allowance under state law is that a clerk, magistrate or district court judge can authorize either a health care provider of the patient or a family member or friend of the patient under involuntary commitment to transport them instead of law enforcement personnel. The health provider, family member or friend may request to transport a patient by submitting a form to the clerk’s office. Hospital staff and magistrates do not usually tell family members about this option and will not authorize it without a specific request.
The Duke Law study authors examined a model in Oklahoma called OK RIDE CARE which contracts with that state’s department of health and human services to provide “trauma-informed transportation services” in unmarked vehicles. The Oklahoma service requires its transporters to be trained in client rights, a therapeutic curriculum approved by the state health department, CPR/first aid, HIPAA compliance and patient confidentiality.
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