Sheriff removes leg cuffs from a psychiatric patient after transporting the man from one hospital to another
A sheriff's deputy removes leg cuffs from Andrew, an 18-year-old psychiatric patient, after transporting him under an involuntary commitment order from UNC hospital in Chapel Hill to Holly Hill Hospital in Raleigh. Photo credit: Sonia Padial

Content warning: This article references suicidal ideation. Please take care when reading. If you need mental health support, call or text the national suicide and crisis lifeline — 988 — or check out our mental health resource page here.

By Taylor Knopf

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 percent 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.

Related story: Mental health patients fill the ER, waiting weeks for help

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.

He’s done IVC training with hospital staff around the state for 25 years. During these sessions, some have told Botts 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 percent 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 that 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 that the psychiatric hospital will not take the patient unless the IVC process has been initiated.

Strain, the UNC Hospital psychiatrist, said that 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 that 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 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 that they would be hesitant to get help next time.

“After the first time I was [IVCed], 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, WBTV reported a story with a video 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 that 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 that the default for transportation has been the sheriff. She added that UNC is currently working on an alternative transportation plan for their mental health patients.

psychiatric patient walks from sheriff's car into the hospital in hand and leg cuffs during an involuntary commitment
Andrew, an 18-year-old psychiatric patient, walks in leg and handcuffs from a sheriff’s car into Holly Hill Hospital in Raleigh after being transported under an involuntary commitment order. Photo credit: Sonia Padial

“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.”

Compounding trauma 

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 includes sources who North Carolina Health News chose to grant a degree of anonymity. We verified the identities and stories of those whose names were changed through interviews and reviews of video and medical records. We 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.

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...

12 replies on “More NC psych patients are ending up handcuffed in a police car. Why?”

  1. i went to an atrum urgent care for a rapid covid test. the nurse asked if i would join a depression study that they were conducting. i said sure. they asked if i considered suicide, yes. how would i do it, pills. the next thing i knew they had called the cops so i ran home. home about 1/2 hour and the cop showed up at my door, but i didn’t let him in. i talked to him through the window. he said what did you go there for. i told him just a covid test. i am 77 and have been on lockdown for 9 months. in may my husband passed away without me being able to say goodbye after 46 years. of course i considered suicide but i am not going to do it. i was scared to death. thanks for listening

  2. An excellent article that explains why transportation of mental health patients in crisis is done as it is. As shown, these modes of transport are often frightening to the patient and exacerbates uncooperative behavior, which is also commonly happens with demented patients who can’t understand what is happening. Rather than “defund the police”, we need to supply them with trained personnel and improved systems that can deescalate the behavior of patients in the process of transporting to the treatment facilities.

  3. Ms Knopf: I had a personal experience with the commitment-shackles-transport procedure. I took matters into my own hands with a different outcome. Should you want to talk to me, I’d be glad to give you the details.

  4. When this happened to me, it was about 15 years ago. I moved to another state for a job that appeared perfect for me. It didn’t work out and I was homeless in the dead of Winter. Desperate and scared, I called my mother and drove back here to WNC. Mother had been our abuser since I was 3 years old. It was only about a week later that Mother kicked me out…
    Mental health turned me away saying I was not listed as a client there… I expressed the suicidal thoughts that had begun to intrude my thinking. I was there for several hours until a police officer was assigned to me.
    I know there were not any cuffs on me and he was very nice. It was almost morning when they had a bed for me. He told me that he was getting off duty, so the next stop would be the police station where a different officer would give me a ride the rest of the way. I was feeling safe, and calm because I now knew I’d be getting help (or so I believed).
    At the police station, he asked me to wait on a bench, which I did. A few minutes later two officers came towards me and they had billy clubs out and one had handcuffs. Suddenly, the fear was back and this time it was as bad as anything I’d ever felt. I was shaking all over and crying. The one with the cuffs grabbed me, twisted me around with my arms behind me and put the cuffs on me very tight. By the time we got to the car my crying was hysterical.
    … In my case I was not just handcuffed, I was beaten….
    The nurse put me in a private room with a female tech and urged me to calm down as the officers were gone. When she came back she had a camera with her and asked if she could take some pictures to document what happened to me.
    She wanted me to use the pictures and a report that she wrote to report the police officers, but I was too afraid that they’d find me.

  5. My thoughts/ opinions- It is interesting that what Psychiatrist Strain told the reporter is different than what happened to the patient mentioned. “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.” I wonder how families are evaluated as suitable for transporting their children. The article does not state that the receiving hospital for the teenage girl mentioned went to a hospital that would not accept voluntary patients. Seems like a contradiction. I wonder if the results here are better explained by it just being easier for providers to file an IVC and feel like they don’t have to explain things to people or respect their rights. Once IVC is filed, perhaps the mindset is to just do whatever you want without explaining anything to children or parents seems to be the way things go. Defensive medicine over humane medicine. What a shame. Strain’s quote of ““We have a ridiculous number of IVCs”, sounds far more like someone who is burned out and needs a different job than someone committed to improving the way that the hospital respects the rights of children and parents.

    1. to my knowledge transport to alternative acute care setting requires the involvement of police due to mechanisms related to liability and stemming from imminent danger. when a person in crisis enters the ER to seek support and a bed is not available the ultimate decsion to transfer their phsyical body to an availble bed becomes one based on similar grounds as to why a a citizen deemed immenently dangerous by layman or magistrate or wellness check gone ary will be removed by police and placed phsyically transporting their immient danger to locked units, == If you meet the criter to be placed a bed you are effective at the point of state liabitliy so a bed for care not availbe at the site in which a person arrive =in no uncertain terms meet the critera to require state law enforcement to protect the community from the imminentdanger of the bodies mind dd

  6. Thank you Taylor Knopf and NC Health News for reporting on this issues. Some things to highlight — how hard it was to get the raw data on the number of IVCs. With all the health data tracked in this state, and the emphasis on how important data is, no official source tracks this data. It took advocates to ferret it out. I worked in an outpatient specialty clinic for 17 years — and we often could arrange voluntary admissions when they were needed. It was a pretty simple process. The overuse of IVCs shows a disregard for human rights. It should be used rarely. Instead, it is used for expediency, and sadly it’s just become a matter of course. Hospital treatment plays a significant role in the treatment of serious mental illness. But if that treatment causes harm, it’s a violation of the most basic rule of medical ethics– first do no harm. There has been a significant erosion of community-based treatment over the past 15 years. We were set on the course in 2001 with a mental health reform plan that resulted in privatization, then slashing of funding and managed care.

  7. when I was at UNC Psych ER, it seemed like they staff liked having so much power. They act like you are bothering them if you ask for anything, yet they take everything away from you, so you can’t do for yourself. There are some good people in psych, but there are others who sort of get off on having power over people. I think a lot of those people work at UNC psych ER for some reason. Years ago, I went to Unc psych and they were nice, but it is totally different now. The head doctor is not nice at all, so I guess the culture follows. It’s all about them not getting sued and showing they are the boss. I bet that’s why they take your phone so you can’t prove what they do. Committing someone doesn’t mean they have no choices. it just means they have to get treatment. It’s wrong what Unc is doing to people there. Sorry there are a “ridiculous” number of IVCs, but each “IVC” is a human being.

  8. Thank you for shining a light on some of the reasons for dehumanizing experiences that people in mental health crisis are often subjected to. We definitely can do better. It makes no sense that someone who has a medical condition that requires specialty care at an alternate facility has choices about how they are transported yet minors (and adults) in NC whose mental health need requires specialty care are criminalized,and often in that process, traumatized. I have personal family experience with this happening as well as psychiatrists making decisions about diagnosis, medication and disposition without even attempting to talk to parents. There is absolutely no excuse for anything shy of collaborative decision making with the patient and his/her loved ones, in the most respectful manner.

  9. No, you don’t have to be under a commitment order to be admitted, however—some insurance companies will not pay unless ‘criteria’ are met and/or a ‘sheet’ is signed. A few years ago, a woman in the ER was severely depressed, had been crying for hours, was requesting admission but BCBS only reluctantly approved overnight because suicidal ideation was not expressed. The next day, they declined further coverage and so she had to discharge.

    1. Certainly shows the difficulty of really being person-centered in mental health crisis situations — we over use coercive strategies, and deny care to those who seek it.

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