This story first published online at North Carolina Health News. 

When two sheriff’s deputies showed up at the hospital room of John Noel’s husband, Chris, he thought he was being arrested. No one had told him they were coming.

The deputies handcuffed Chris and escorted him to the back seat of a patrol car, according to Noel. Driving away from the hospital, Chris asked the officers if they were taking him to prison. They ignored his questions.

(NC Health News verified Chris’s identity and chose not to identify him by his real name due to the ongoing stigma of mental illness and involuntary commitment.)

The officers were taking Chris from the emergency department at Duke Regional Hospital in Durham to Holly Hill Hospital, a psychiatric facility in Raleigh under an involuntary commitment order.

Meanwhile, Noel was at home and had no idea. Had he known about the order, Noel says he would’ve tried to prevent it or driven Chris to Holly Hill himself.

Involuntary commitments are ordered by a judge when a person is determined to be a danger to themselves or others. In most North Carolina counties, a commitment order triggers a call to law enforcement to transport the patient to a hospital to be evaluated or to an available psychiatric bed. The nearest opening could be located at a hospital several hours away.

Amid local and national conversations about “defunding the police,” this practice is getting a new look. Even law enforcement officials are asking if some of the roles assigned to them—such as transporting mental health patients and responding to mental health crises—should be done by professionals with a different set of skills.

Increasingly, sheriffs across North Carolina appear to be agreeing with mental health advocates on this point.

Transporting psychiatric patients

More and more patients have found themselves handcuffed in the back of a police car over the last several years. NC Health News reported a 91 percent increase in involuntary commitment petitions over the decade prior to the pandemic, far outpacing population growth in the state.

North Carolina counties are required by state law to provide secure transportation for psychiatric patients under an involuntary commitment order. In most counties, sheriffs’ departments are tasked with this job.

But many sheriffs say they do not want this responsibility anymore.

In March, the NC Sheriffs’ Association released an updated report on “law enforcement professionalism” in response to the national protests and conversations about the responsibilities of law enforcement that erupted after the death of George Floyd.

Among the list of changes and requests, the sheriffs ask state lawmakers to pass legislation removing their role of transporting patients under involuntary commitment. The sheriffs said that mental health professionals should be transporting these patients and they also ask for more state funding for substance use and mental health treatment.

“I believe that it is the general feeling of the law-enforcement community that persons with mental health needs should more appropriately receive the services that they need from mental health professionals and mental health facilities rather than from law-enforcement officers or the county jail,” Eddie Caldwell, general counsel to the NC Sheriffs’ Association, told NC Health News in an email.

Caldwell has previously explained how transporting patients under involuntary commitment orders strains those sheriffs’ departments with fewer resources, especially when they have to drive patients hours across the state.

The request from the sheriffs’ association could be a pivotal point for North Carolina’s involuntary commitment process, which advocates say currently compounds the trauma for many patients by involving law enforcement. However, there’s a concern that county officials may shift transit responsibilities from deputies to contracted security companies that have less oversight than government agencies.

“Felt like a prisoner”

One night in February, Noel and Chris were getting ready for bed at their home in Durham when Noel said his husband suddenly seemed to be in a “parallel universe.” He was restating claims from a past psychotic episode and trying to leave the house carrying a backpack full of mustard to fix a problem at a six-figure job he no longer had, Noel recalled.

Noel said they needed to go to the emergency room, and Chris—who was recently diagnosed with type 1 bipolar disorder—didn’t argue and went willingly.

What Noel didn’t expect was five days to pass before he heard Chris’s voice, calling from Holly Hill. Noel claims that no one at Duke Regional or Holly Hill would confirm where his husband was during the five-day interval.

Chris described how confused he was when officers handcuffed him and put him in the back of a cruiser. He said he felt like a prisoner and asked Noel, “Why did you put me here?”

“It really just broke my heart that he went through that,” Noel told NC Health News later. “I was both angry and crying at the same time. I just felt like I had failed him somehow.”

In 2019, counties were tasked with rethinking how they transported patients like Noel’s husband after a state law went into effect aimed at reforming parts of the involuntary commitment process. County leaders met and most submitted updated transportation plans to the state health department.

NC Health News reviewed those plans and previously reported that most counties chose to continue using local law enforcement for patient transportation. A very small number opted to contract with private security companies or local EMS to transport patients.

Opting for private security guards

Mental health advocates are concerned that as counties and behavioral health management groups look for alternatives to police transports, more will default to contracting with G4S, a private security company already used by a couple of counties. The state of Virginia recently awarded G4S a $7 million contract to transport nearly half of its mental health patients under involuntary commitment instead of law enforcement.

“Having off-duty police officers or security guards transporting is not what is meant by an alternative to police transport,” said Cherene Allen-Caraco, director of Charlotte-based Promise Resource Network, a mental health services agency run by people with lived experiences of mental illness, incarceration, homelessness, and substance use.

Allen-Caraco advocates for noncoercive, nonrestrictive mental health treatment and support. She doesn’t want to see more patients transported by private security officers, who she said receive little pay or training for the role. She also pointed to an incident last year in Charlotte when a G4S security guard was charged with sexual assault of a minor after allegedly raping a 14-year-old girl he was transporting to the hospital under an involuntary commitment.

G4S has been transporting mental health patients since 2012, according to a spokesperson for Allied Universal, which acquired G4S last year.

“Allied Universal employees entrusted with this role go through enhanced training focused on healthcare essentials, de-escalation, safe driving, and safety near or around stairs. Additionally, Allied Universal has a certified Mental Health First Aid Trainer on staff to train all new hires in this role. Allied Universal employees also receive training from third parties and client-specific training on working with individuals with autism and other conditions,” a spokesperson wrote in an email to NC Health News.

A number of North Carolina counties’ updated transportation plans included a clause with an option to use a contractor like G4S in the future. Other plans had details about using officers of the same gender as the patient when possible or officers in plain clothes rather than full uniform.

A handful of plans went so far as to lump together prisoners and mental health patients in their transportation plans. And in some cases, the transportation of incarcerated people and psychiatric patients looks very similar.

Criminalizing mental health

Nine years ago, sheriff’s deputies loaded Susan Silver’s daughter, Anne, into a prisoner transport van and drove her from an emergency department in Wilmington to a psychiatric bed two hours away in Greenville. It was the same kind of vehicle Silver would see sitting outside the courthouse each weekday.

(NC Health News verified Anne’s identity and chose not to identify her by her real name due to the ongoing stigma of mental illness and involuntary commitment.)

Silver recalls watching her then 25-year-old daughter shuffle out of the hospital to the van with her wrists and ankles shackled together and attached to a chain around her belly.

“This, of course, in full view of everybody in the department and in the hallways and everywhere else, and with a deputy on either side of her like she was a criminal,” Silver said.

Inside the van, Anne sat on a wooden bench in the middle compartment closest to the front of the vehicle. She couldn’t see outside. Silver remembers her daughter being locked inside the van in the parking lot for close to an hour as the deputies waited on a second male patient they needed to drive to Greenville too.

“I was pretty nearly hysterical,” Silver recalled. “I’m shouting at someone to let her out and give her some air, and they’re telling me that they’re not doing any such thing because this is policy.”

On the drive, the second patient urinated onto the metal floor of the van, and the fluids swished back and forth between the two caged compartments. Anne told her mother that she sat with her legs on the bench to avoid getting wet.

“Mom, don’t ever let me do that again,” Anne said when they finally spoke in Greenville. That incident prompted Silver to complain to the New Hanover County sheriff, saying her daughter was treated like a “dangerous criminal.”

“People like my daughter suffer long-lasting consequences from that kind of trauma,” she said. When Silver adopted Anne as a young child, she already had a history of trauma as well as an intellectual disability and emotional and behavioral health issues.

Some time later, Anne needed another ride to a psychiatric hospital, and New Hanover deputies showed up in a regular patrol vehicle without the handcuffs. There were magazines and a blanket in the back seat. Silver said she thanked the sheriff for the improved treatment.

However, some psychiatric patients in New Hanover County are still transported in vans with caged compartments inside, according to the sheriff’s department. The kind of vehicle the patients are put in depends on logistical factors, including their age, availability of staff and vehicles, and how many patients need to be transported from one hospital to another at the same time.

Advocates have cautioned against the use of vehicles with caged compartments to transport mental health patients for safety reasons after two South Carolina women drowned inside a law enforcement van swept away by floodwaters during Hurricane Florence. The officers driving the van managed to escape.

In New Hanover, the transport vehicles have no markings on them that would distinguish them as law enforcement vehicles, according to Doug Price, a major with the New Hanover Sheriff’s Office. He said his officers dress down when transporting patients and only use handcuffs when necessary.

“Strain on the squad”

Though law enforcement officers have been transporting psychiatric patients for decades, some patients are still caught off guard when the deputies arrive at their home or hospital room.

“I can say from experience that when they go to the hospital voluntarily and they get put on [involuntary commitment] papers, sometimes the hospital staff might not tell them that they’re getting placed somewhere,” explained Christopher Miles, head of the transportation unit at New Hanover Sheriff’s Office.

“So sometimes it’s a shock to them when they see us come in, but once we speak to them and tell them the situation, from my experience, they tend to relax,” Miles said.

Price added that his officers receive more pushback from family members of patients who want to drive their loved one themselves, something allowed under North Carolina law. Getting an exception to drive a loved one can be tricky, as hospitals tend to be risk averse and prefer law enforcement officers to transport patients.

In New Hanover County, the sheriff’s department has a dedicated transportation unit that’s responsible for taking incarcerated people to court and doctor’s appointments and between prisons. The unit also drives mental health patients under involuntary commitment.

Not all counties have that luxury.

“There’s 100 counties in North Carolina, and some of the smaller agencies don’t have as robust of a transportation unit and it becomes a strain for them,” Price said.

“When I first started, you would carry your IVC patient to the hospital and you would sit with that IVC patient sometimes for four, five, six, seven hours and then you would carry him somewhere else, so it was a strain on the squad,” he said.

Over time, New Hanover deputies were asked to transport more patients farther distances across the state, so the department made a change to address the rising demand. Now, one frequent placement for patients from Wilmington is Old Vineyard Behavioral Health Services three and a half hours away in Winston-Salem, Price explained. His department recently met with local hospital officials to ask if patients could be placed closer to the county.

“Warm receiving atmosphere”

The presence of law enforcement doesn’t help a person in a mental health crisis, whether they’re in the hospital or experiencing a crisis in the community, according to Mecklenburg sheriff Gary McFadden.

“The uniform presence is threatening, no matter what we do. And the car you’re coming in is threatening also. It escalates the situation,” McFadden said. “Khaki pants with a polo shirt that says something else on it—you’ll be fine.”

McFadden added that the hours and hours of transporting patients under involuntary commitment are stressful for his officers and the patients.

“It’s that warm pickup,” he said, pausing. “If we could change anything, it could even be the car that they travel in or how they travel. They travel with an officer with a gun and a badge, and they’re in a caged area in the back of these vehicles. Why can’t we take a look at how we can give them better transportation to the next facility?”

Law enforcement doesn’t need to respond to every situation, especially to nonviolent incidents involving people with mental health issues, McFadden explained while sitting on the porch of Promise Resource Network’s new peer-run respite after its launch event last year. McFadden supports using mobile mental health response crisis teams and peer support inventions, offered by trained people with their own experiences of mental illness, substance use, or homelessness.

“A warm receiving atmosphere helps soothe these people. An organization like this, we can learn from,” McFadden said, gesturing to the new space available in Charlotte as an alternative to hospitalization for people in mental health distress. “These are people who have been through this. They are the consumers of what we’re talking about.”

Wrong role for law enforcement

While zigzagging down a dark street in Greensboro in 2018, Marcus Deon Smith encountered police officers and asked for help. With blue lights blinking around him, Smith appeared distressed and disoriented as officers shined flashlights in his face and tried to usher him into the back of a police cruiser.

In a video captured by police, 38-year-old Smith told the officers that he wanted to go to the hospital and that he was not resisting them. Smith appeared more distressed inside the vehicle so the officers used a controversial, but legal, “hogtie” restraint on him which triggered a heart attack. Smith died before reaching the hospital.

The medical examiner ruled Smith’s death a homicide, and his family recently reached a $2.57 million settlement agreement in their wrongful death lawsuit against the Greensboro Police Department. However, the officers involved were not disciplined. The mayor and then police chief said the officers didn’t do anything wrong and acted as they were supposed to, according to a report by The Assembly.

In response to Smith’s death and the following conversation in Greensboro, two North Carolina–based researchers wrote a model law that municipalities could adopt to better respond to people in mental health crises.

“[Smith] needed help from someone who understood his lived experience and who could deescalate his behavioral health crisis humanely. He needed a person-centered behavioral health crisis response team,” argue Taleed El-Sabawi and Jennifer Carroll, authors of the model law.

Their model could be used as a legal framework to start a program such as Crisis Assistance Helping Out on the Streets—better known as CAHOOTS—where mobile response teams made up of a medic and a mental health crisis worker respond to 911 calls related to mental illness, homelessness, and substance use. Each CAHOOTS team member has more than 500 hours of training.

The program was established over 30 years ago in two Oregon cities and has since been replicated in other states. In 2019, the CAHOOTS teams in Oregon responded to more than 24,000 calls and only requested police backup 250 times. The program in Oregon estimates that it saves the local government $8 million on public safety and $14 million on ambulance and emergency room treatment annually.

Studies have shown that people with mental illness are more likely to be injured by law enforcement during an encounter and that people who have psychotic episodes have more interactions with law enforcement as a result of their mental illness than others. People with untreated mental illness are 16 times more likely to be killed by police, according to a study by the Treatment Advocacy Center.

In their academic paper, “A model for defunding: An evidence-based statute for behavioral health crisis response,” El-Sabawi and Carroll explain how Crisis Intervention Training (CIT) for officers—a favored program aimed at helping them better understand mental illness—isn’t actually working.

The core of the program is a 40-hour training in the signs of mental illness and crisis deescalation techniques. Since the training was born in the late 1980s, more than 3,000 law enforcement agencies have adopted it.

“Little evidence exists to show that the CIT approach is effective at reducing incidents of police use of force (or even simply reducing incidents of excessive police use of force) during behavioral-health-related calls,” El-Sabawi and Carroll argue.

They conclude that officers lack training, institutional support, infrastructure, culture, and public image to respond to mental health calls effectively. They say the program is asking law enforcement “to be something that they are not.”

“Therefore, first responders to behavioral-health-related calls for service should not be law enforcement,” they argue. “First responders should consist of a different set of service professionals entirely.”

Not going back

Patients and their family members are often shocked and traumatized when officers arrive at their home or their hospital room to transport them to the hospital, often in restraints.

“This is a person who’s in a crisis already, and they’re just making it worse,” Noel said, recalling the effects of the process on his husband. “I think this is a broken process here and it needs to be fixed.

“The hospitals aren’t happy with it. The sheriffs aren’t happy with it. The patients aren’t happy with it. The families of the patients are not happy.”

In Mecklenburg County, assistant public defender Bob Ward represents patients under involuntary commitment almost daily and says his clients often describe the additional trauma they feel due to law enforcement involvement in the process.

“It does get in the way of them fully embracing the treatment,” Ward explained. “They are angry. They are anxious. They feel belittled. They feel dehumanized. They say, ‘I’ve done nothing wrong, but I felt like I was being treated like a criminal.’”

Noel said his husband is doing better right now. Chris got a new job, and his medications and treatment appear to be working. But Noel said he lives “in dreaded fear” of what he’ll do if Chris has another severe psychotic episode.

“Because I cannot turn to the emergency room,” he said. “I will not do that again.”

Noel and his husband aren’t alone. Many family members and psychiatric patients say they will not return to the emergency room for psychiatric care in the future after similar experiences.

Studies show that this type of forced treatment deters people from seeking help in the future and increases the risk of suicide. A survey of about 450 people who have gone through coerced psychiatric hospitalizations, created by people who had been subjected to involuntary commitments, found that 53 percent said they attempted suicide after their hospital stay and 78 percent said they had post-traumatic stress symptoms from the experience.

The majority said they would hesitate to or not tell their mental health provider about suicidal crises in the future.

North Carolina Health News is an independent, nonpartisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina.

This story was supported by a grant from the Fund for Investigative Journalism.  

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