By Taylor Knopf

When it comes to dealing with people who have mental illness, most people think hospitalization is good and jail is bad, but according to Cherene Allen-Caraco “both of them are indicators of system failures.”

Allen-Caraco has served people with mental illness through Promise Resource Network, a provider of mental health services in Charlotte for 16 years. Of the thousands of people she and her team have served, they’ve only involuntarily committed one person to a psychiatric hospital.

“Sometimes in an effort to divert people from jail, we put them in another form of confinement,” she said of forced psychiatric hospitalizations.

That type of hospital admission, known as involuntary commitment or IVC, is a legal process in which someone asks a judge to order forced psychiatric treatment when a person is thought to be an immediate danger to themselves or others.

During that exceptional situation, Allen-Caraco said the man was “intentionally attempting to get ‘killed by cop.’” When she met him a few years earlier, the man had been living on the streets for 20 years with little-to-no human interaction.

“He is that one exception to the rule where he was so unhealthy and so unwell,” she said. “When it got to the point where it was clear he could not keep himself safe, we had to do the IVC.”

As a survivor of complex trauma herself, Allen-Caraco advocates for non-coercive mental health interventions that support wellness and recovery. She founded Promise Resource Network, which served nearly 2,000 people per month in 2019 at its mental health recovery hub in Charlotte offering classes, activities, support, bus passes, showers and more to people living with mental illness. 

A photo of a young woman, she is Cherene Caraco, who leads a peer support organization called Promise Resource Network
Cherene Allen-Caraco, CEO of the peer-run Promise Resource Network. Photo courtesy of Cherene Allen-Caraco. Credit: Cherene Allen-Caraco

Promise Resource Network is staffed by people who can relate to the struggles of others — known as peer support specialists — because of their personal experience with mental illness, homelessness, substance use, incarceration or a combination of those experiences. The organization uses an array of crisis intervention options — such as warm lines, mobile crisis teams and peer-run respites — to support people in mental health crises while keeping them out of jails and psychiatric hospitals. 

Forced psychiatric hospitalizations, often initiated by loved ones, health providers and emergency departments, are on the rise in North Carolina. Some state lawmakers took note and introduced a package of mental health bills that would provide alternative interventions, such as non-police crisis response units and more organizations like Promise Resource Network.

Why so many involuntary commitments? 

Mental health providers and advocates agree that breakdowns in community mental health services have driven more people experiencing psychiatric crises — such as hallucinations, suicidal thoughts or psychotic symptoms — to emergency departments. They often languish for days or weeks in the emergency room waiting for an inpatient bed to open up for them somewhere. 

During the COVID-19 pandemic, state data shows wait times averaged more than eight days, an increase of two days over the prior year-long period.

Many of these patients are involuntarily committed — some are necessary, others are initiated for inappropriate reasons. NC Health News analyzed and reported data showing that involuntary commitments increased by 91 percent over a decade, far outpacing the state’s population growth.

This mirrors national trends. A recent study published by the American Psychiatric Association 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. 

Involuntary commitment orders issued by a judge in North Carolina trigger a call to law enforcement. Then police officers or sheriff’s deputies respond to mental health crises in the community or to transport involuntary commitment patients waiting in a clinic or ER — usually in handcuffs and ankle shackles — from one hospital to another. 

Transporting patients in a fragile state of psychiatric crisis in restraints by police is widely criticized by mental health advocates. They argue the practice can be traumatic and stigmatizing for patients. 

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

For their part, sheriffs say that transporting IVC 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.

“I think everyone was put back on their heels with several events across the country last year that showed that there might be solutions to folks in crisis that could be better addressed and managed by personnel prepared for such encounters, other than police officers,” said Rep. John Autry (D-Charlotte), who is a primary sponsor on a package of four mental health bills.

Non-police response to mental health crises

One of these bills (House Bill 786) would set up a $2 million pilot project grant fund for police and sheriffs’ departments to establish eight non-police crisis response units and seven co-responder response models, in which law enforcement and mental health specialists would go to mental health crisis calls together.

The remainder of the funds would be used for more officers and for 911 communications personnel to receive Crisis Intervention Training (CIT), where they would learn tools to better communicate and de-escalate crisis situations. 

The non-police response units would be staffed by trained community responders to “address nonviolent, noncriminal 911 calls regarding mental health, homelessness, substance use, or other behavioral health crises.” 

Allen-Caraco relies on non-police mobile crisis teams in Mecklenburg County to respond to and access the health needs of the people she serves. 

Rep. John Autry (D-Charlotte). Photo courtesy of the NC General Assembly

“When a police officer arrives at a scene, people of color and people in poverty scatter,” said Allen-Caraco, who helped shape recommendations for these bills. “Even if the officer is well-equipped with the right mental health and de-escalation training, there is a historic distrust of law enforcement and their presence automatically escalates the situation.”

“These are not criminal or legal situations,” she said. “This is a health situation.”

Last summer, Autry said he was approached by former football coach turned policy analyst, Jarrod James, who became the linchpin for this project, pulling together advocates and experts to craft these mental health bills. 

“Everything that happened with George Floyd, Breonna Taylor and Ahmaud Arbery really convicted my spirit to do something,” James said. 

He started looking at alternatives to police response in mental health situations and pulling advocates and lawmakers together  — including three Republicans who lead the House health committee.

Rep. Donny Lambeth (R-Winston-Salem), co-chair of the House health committee, said he’s concerned about the “fragile” state of North Carolina’s mental health system amidst an increase in demand for services during the pandemic. 

“At some point, the General Assembly will need to address these issues, and these bills help shine the spotlight on some of these issues,” Lambeth said. 

James said the work group looked closely at the Denver STAR model in Colorado, which deployed non-police units to more than 2,500 crisis incidents in its first six months. No arrests were made, and the Denver police chief said he’s happy with the program. 

The CAHOOTS program founded in 1989 in Oregon has also been held up nationally as a cost and life saving model for non-police crisis intervention.  The program, embedded in the local emergency services, is designed to handle noncriminal, non-emergency police and medical calls with mental health professionals, for example, rather than sworn police officers. These are examples of programs that could be created in North Carolina under House Bill 786. 

Establishing peer-run wellness centers 

One proven way to break the cycle of hospitalizations is by intervening beforehand with peer-driven support from people who know what it’s like to have a mental illness, which is the model at Allen-Caraco’s organization Promise Resource Network. 

House Bill 788 would provide $600,000 to Promise Resource Network to create four peer-run wellness centers in the state, two in urban settings and two in rural communities. The bill aims to “address mental health crisis prevention and post-crisis response.” House Bill 788 would also create a position at the NC Department of Health and Human Services to oversee peer-driven mental health recovery efforts.

The demand for services and classes at Promise Resource Network continue to go up. Some classes are standing room only, Allen-Caraco said. The key is that everything is completely voluntary. 

“They come to the things they find meaningful,” she said.

The rise in mental health patients in crisis at the emergency department is a sign that what we have isn’t working for people, Allen-Caraco said. 

“We have dismantled our community mental health system so much so that involuntary commitment is completely overused because people feel like this is no alternative;” she said. “We have to create alternatives.”

There are a handful of other peer-support centers in the state, including Green Tree in Winston-Salem. Though much smaller than its Charlotte counterpart, Green Tree served 150 people in 2019, and only four of those people needed to be hospitalized for mental health services during that time. 

“We rarely have participants go to the hospital, and these are people who are most frequently hospitalized,” said Green Tree director and founder Laurie Coker. As a former psychiatrist nurse with a personal connection to mental illness, Coker has been an active voice for mental health reform in the state and a driver behind this latest package of bills.

woman stands at a table, papers scattered in front of her. the typewritten notes have scribbled notes in the margins and between the lines.
Long-time mental health advocate Laurie Coker references her notes as she speaks to Sen. Tommy Tucker after the presentation of the state’s new behavioral health strategic plan in 2018 at the General Assembly. Photo credit: Rose Hoban

Though Green Tree offers voluntary wellness groups and classes, there are always some participants who simply come to hang out and connect with others and “feel safe for a few hours every day,” Coker said.  

Whether they participate in classes or not, Coker says she’s seen a decrease in the need for hospitalization for everyone. 

“Social connection is a misunderstood and undervalued ingredient,” she said. 

Need for data and certification

No one at the state level is keeping track of involuntary commitment trends. When NC Health News originally sought to report on these issues, there was limited data available. A group of determined advocates tracked it down.

Currently, a basic tally of petitions for involuntary commitment are kept by each county’s clerk of court and reported to the NC Administrative Office of the Courts, which lumps them together with other special proceedings. 

House Bill 787 would require creation of a biannual reporting requirement of involuntary commitment data, including several other data points that would tell more about how people encounter and move though the system. For example, it would track how many commitments are upheld; how many are transported to an inpatient facility; and the length of stay.

“How can we expect to make good policy if we don’t have good data?” said Autry, the lead sponsor of the bill.

Additionally, House Bill 732 would set up a certification process for peer support specialists, which would create a vetting structure for the people who are being increasingly relied on to provide support in mental health and substance use settings. 

However, House Bills 787 and 732 were not heard in committees before the legislative deadline known as “crossover” last week. Therefore, it’s unlikely they will move forward during this session. The previously mentioned bills, House Bills 786 and 788, are still in the House health committee but are not subject to the same deadline because they include a fiscal appropriation.

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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...