An Urgent Call for Change
Note: This report details traumatic and disturbing experiences of people subjected to involuntary commitment
Executive Summary
North Carolina is facing a profound mental health crisis. Increasing numbers of children and adults are in urgent need of care, but too often, the services they need are unavailable, inaccessible, or nonexistent in their communities. In this vacuum of support, involuntary commitment (IVC)—a legal process intended as a last resort—has become a default response. What was once meant to be a narrowly applied intervention has devolved into a widespread, expensive, wasteful, and abusive practice that is failing those it purports to help. We rely on costly emergency department (ED) and psychiatric hospital care instead of care in communities that costs far less and is more effective.
For more than a year, Disability Rights North Carolina (DRNC) focused intensively on NC’s IVC process and how it plays out on the ground. Using its federally mandated authority, DRNC monitored 10 EDs throughout the state, interviewed people with lived experience and their families, and consulted mental health professionals, legal scholars, and hospital staff. The findings reveal a deeply flawed system that causes lasting harm instead of delivering help.
Key Findings
North Carolina’s IVC process is marked by systemic overuse, misuse, and harm:
- Lack of Due Process. People are detained in EDs under civil custody orders without appointed legal representation or timely judicial oversight. They remain in legal limbo, often for days, weeks, or months, awaiting psychiatric placement.
- Traumatic Detention. Individuals—including some young children—are subjected to strip searches, physical restraints, forced medication, handcuffs and shackles in transport, and long periods in EDs, some noisy, harshly lit, and chaotic, with little to no treatment.
- Harm to Families and Communities. The IVC process often excludes parents and guardians from decisions, disrupts lives, causes job loss and financial hardship, and consumes law enforcement and hospital resources unnecessarily. These damaging experiences make some people reluctant to seek out psychiatric care when needed.
- Systemic Failures. The process lacks adequate data tracking and evaluation. However, from the scant data that does exist, we know that at least 63% of IVC petitions over the last six years have not resulted in actual commitments, highlighting widespread inappropriate use. This affects tens of thousands of people in NC each year.
- Misuse. IVC is sometimes used by nursing homes and assisted living facilities to expel residents, by family and friends as a form of control, and by providers as a means of shifting care responsibilities—rather than addressing mental health needs compassionately and effectively.
Despite these grave issues, positive developments are underway. Some enlightened community leaders are innovating creative solutions to support healing in their communities and keep people out of crisis. We need more of them. The NC Department of Health and Human Services (NC DHHS), together with increased funding from the NC General Assembly, has launched substantial efforts to develop and deliver more services to help people get the care they need to remain in their communities. They are also developing community crisis resources to help people access crisis care if they get to that point.
NC needs more trauma-informed, person-centered approaches to mental health services in communities. Innovative alternatives—including mobile crisis teams, peer support networks, and community-based care—are effective, humane, and recovery-focused. These solutions need urgent expansion and support.
Recommendations for Change
To address this crisis and rebuild a more humane and responsive, less abusive and wasteful system focused on care and healing, DRNC makes five key recommendations:
- End Misuse and Overuse of IVC
- Mandate specialized training for magistrates.
- Require crisis screenings by mobile crisis teams before magistrates issue custody orders.
- Ensure alternatives like the NC Peer Warmline, 988 crisis line, or mobile crisis teams are considered first.
- Penalize misuse, including repeated or frivolous petitions.
- Reduce Harm During Transport
- Replace law enforcement transport with trained, non-coercive transport.
- Eliminate unnecessary use of shackles, uniforms, and marked cars.
- Require trauma-informed training for all transporters and give families the option to transport loved ones.
- Reduce Harm in Facilities and Courts
- Provide immediate legal representation once a custody order is issued.
- Amend NC law to eliminate successive petitions.
- Involve supportive guardians and children’s parents in care decisions and court processes.
- Allow a parent or legally responsible adult chosen by the child to be present when a minor is strip searched.
- Shorten the timeline for court hearings from 10 to 5 days.
- Mandate trauma-informed care and strengthen oversight of facility practices.
- Build Out Evidence-Based Alternatives
- Expand peer support and non-coercive crisis response models like HEART in Durham.
- Prioritize community-based prevention and treatment.
- Involve people with lived experience in designing solutions. Peer support works.
- Collect and Share Critical Data
- Require detailed reporting on IVC processes, outcomes, and costs.
- Establish public dashboards to ensure transparency and accountability.
- Use data to inform policy and identify breakdowns in care.
The path forward is clear: NC must transform its mental health system from one rooted in abuse, coercion, trauma, inefficiency, and waste to one centered on prevention, dignity, and effective care. The goal is not simply to reduce IVC; NC must do better to prevent the crises that make IVC seem necessary in the first place.
This will require a determined effort from various stakeholders, including state and local elected officials; policy makers within DHHS; provider agencies and hospitals; among others – and must include and center people with lived experience in the creation of solutions.
People with mental health needs deserve healing, not harm. They deserve support in their communities, not detention in emergency rooms. The state must act with urgency to invest in person-centered care, legal protections, expansion of peer support services, and community-based solutions. Only then can NC ensure that all people—especially those in crisis—have the opportunity to heal, thrive, and live with dignity.