By Emma Kaplon
By law, the state of North Carolina must provide assistance to individuals in mental health crises. Many voluntarily admit themselves to care facilities, while others, legally deemed dangerous to themselves or others due to mental illness or substance abuse, are involuntarily committed. Autonomy is stripped from the mentally ill individual for their safety while a judge decides whether they should be treated in a mental facility. Data shows that involuntary commitments continue to multiply across North Carolina, and conversations about the benefits and detriments of the system become increasingly pertinent (Giles 1). In interviews through the Stories to Save Lives research project with the Southern Oral History Program, patients and their family members such as Jim Kellenberger, Donna Smith, Donald Smith, and Nicholas Stratas have been able to share their perspectives and experiences with involuntary commitment in North Carolina. As evidenced by both statistics and personal narratives, involuntary commitment to mental facilities may be a necessary means of maintaining patients’ safety; however, it may also cause harm to mentally ill patients. The mental health care system in North Carolina must find a way to reconcile these opposing truths and reevaluate laws and protocols for involuntary commitments in the state.
Improving Patients’ Lives
In many situations, this course of action benefits the life of the patient, and involuntary commitment improves both their temporary psychological state and their future. The process of involuntary commitment is necessary for patients who are unable to personally make safe decisions. In an interview for the Stories to Save Lives Project, Jim Kellenberger shares his support for involuntary commitment based on his mother’s treatment in a facility in the 1950s:
“If you’re walking around naked in public in broad daylight, and talking to the stars…to simply say that you’re going to let folks who do have this disease make their own decision about going there, I think is a wrong concept” (Kellenberger 19:07-20:38)
Recognizing the way that involuntary commitment protected his mother, he believes that the practice remains crucial to mental health care. Like Kellenberger, Stories to Save Lives interviewee Donna Smith explains the way that involuntary commitment helped ensure the safety of her son Donald. When he was going to be discharged from a voluntary mental facility for the third time in a year, she sought involuntary commitment to allow him to complete treatment:
“I fought the discharge because he wasn’t ready…And we went through the revolving door two other times. They were going to put him out again, and I couldn’t keep doing it. So I pushed. I made them do an involuntary commitment hearing” (Smith 31:46-31:57).
Generalizing the Smiths’ experience with statistical data, Dr. Gustavo Fernandez and Sylvia Nygard conducted a study to evaluate the way that involuntary outpatient commitments influence revolving-door syndrome in North Carolina facilities. Revolving-door syndrome refers to the phenomenon when patients spend limited time in mental facilities, stop seeking treatment, and are repeatedly rehospitalized (Fernandez 1002). Fernandez and Nygard’s findings demonstrate a drastic reduction in the number of times a person is admitted to an inpatient facility after their period of involuntary commitment, decreasing from an average of 3.69 times to 0.66 times. If they are readmitted, the number of days they spend as an inpatient also decreases from 57.6 days to 38.4 days (Fernandez 1003). Involuntary commitment has lasting benefits for patients because they are less likely to need to be treated in the future; however, involuntary commitment is not always used as a tool to protect mentally ill individuals and help them receive proper care.
Causing Further Harm
Individuals in mental health facilities may be harmed by the process of being involuntarily committed and the conditions of their treatment. Though Donna Smith shares her support for involuntary commitment, her son Donald reveals the point of view of the patient, describing the stigma of being mentally ill and his fear when being committed:
“They bring you in the door, but then they’re putting handcuffs on you…the things they put on people when they’re ball and chain. They have this great fear of you and what you can do…So it’s very easy for someone who doesn’t know the ropes, doesn’t know what’s going on, to freak out” (Smith 14:15-14:30).
He explains the lack of compassion that individuals experience when being involuntarily committed and the emotional trauma caused by the process. In another interview Nicholas Stratas mourns the terrible conditions his father experienced in a provincial hospital when he was involuntarily committed with bipolar disorder:
“He was hospitalized against his will…And conditions were terrible…people just lying in the halls” (Stratas 14:27-14:37).
Unfortunately, this inhumane treatment of people in institutions is not unique to Stratas’s father. Georgetown public health law professor Lawrence Gostin studies cases of patients’ loss of liberty and dignity after being involuntarily committed, sometimes being isolated in small unclean spaces, beaten, or denied clothes or nutrition. One man was unnecessarily sedated and tied to a hospital bed for weeks (Gostin 908-909). Though these stories are extreme, many suffer the consequences of poor treatment in mental health facilities after being involuntarily committed.
Reforming the System
The question remains: how can North Carolina improve a mental health system that is both necessary and deeply flawed? Mentally ill individuals sometimes need legal intervention to protect their well-being and help them receive treatment when they are unable to make safe unilateral decisions. However, after being taken to mental health facilities where they are meant to be cared for, poor living conditions and abuse leave patients with further trauma. The health care system must structure a new mental health facility that prioritizes the well-being and safety of patients by not only addressing immediate risks but also mitigating fear through compassion. This model has been successful in facilities like Dorothea Dix Hospital, a psychiatric hospital that recently closed in Raleigh, North Carolina, which was able to provide care in a safe and encouraging environment. Both Donna and Donald Smith note in their interview that in Dorothea Dix Hospital, Donald was treated with respect and kindness, and he saw long-lasting improvement in his mental health. Dr. Marvin Swartz, a psychiatrist at Duke University, and Dr. Joseph Morrissey, a professor of Health Policy and Management at the University of North Carolina at Chapel Hill, write that despite the challenges of finances and workforce shortages, with leadership from the Governor, General Assembly, North Carolina Department of Health and Human Services, and local advocates, mental health care reform for systems like involuntary commitment is possible.
Involuntary commitment in mental health facilities in North Carolina is a complex issue because it is both necessary and often harmful for patients. However, the public mental health system in North Carolina can feasibly improve patients’ experiences by amending laws and protocols for involuntary commitment and prioritizing trust and compassion at institutions like Dorothea Dix Hospital.
Botts, Mark. “Criteria for Involuntary Commitment in North Carolina.” UNC School of Government, 2009, www.sog.unc.edu/sites/default/files/course_materials/Fall%202011%20Conf-Botts.pdf. Accessed 24 Apr. 2022. Infographic.
“Dorothea Dix Hospital Admits Its First Patient.” NC Department of Natural and Cultural Resources, 22 Feb. 2016, www.ncdcr.gov/blog/2016/02/22/doors-at-dix-hospital-opened-1856. Accessed 24 Apr. 2022.
Fernandez, Gustavo A., and Nygard, Sylvia. “Impact of Involuntary Outpatient Commitment on the Revolving-Door Syndrome in North Carolina.” Psychiatric Services, vol. 41, no. 9, Sept. 1990, pp. 1001-04, https://doi.org/10.1176/ps.41.9.1001. Accessed 3 Mar. 2022.
Giles, Krystal L. Policy Analysis of Involuntary Commitments and Transporting Persons with Mental Illness in Wake County, North Carolina. 2018. North Carolina Central U, PhD thesis. ProQuest, https://libproxy.lib.unc.edu/login?url=https://www.proquest.com/dissertations-theses/policy-analysis-involuntary-commitments/docview/2037314447/se-2?accountid=14244. Accessed 10 Mar. 2022.
Gostin, Lawrence O. “‘Old’ and ‘new’ Institutions for Persons with Mental Illness: Treatment, Punishment or Preventive Confinement?” Public Health, vol. 122, no. 9, Sept. 2008, pp. 906-13, https://doi.org/10.1016/j.puhe.2007.11.003. Accessed 8 Apr. 2022.
Kellenberger, Jim. Interview with Caroline Efird. 4 January 2019 (Y-0063). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
North Carolina Department of Health and Human Services. “NC Involuntary Commitment Process (IVC): Inpatient Treatment.” NCDHHS, Feb. 2019, www.ncdhhs.gov/media/8756/download. Accessed 24 Apr. 2022. Chart.
North Carolina State, General Assembly, Assembly. Mental Health, Developmental Disabilities, and Substance Abuse Act of 1985. North Carolina General Assembly, 1985, www.ncleg.gov/EnactedLegislation/Statutes/html/bychapter/chapter_122c.html#:~:text=%C2%A7%20122C%2D2.,of%20all%20North%20Carolina%20citizens. Accessed 10 Mar. 2022. Assembly Document Chapter 122C.
“‘Revolving Door’ Syndrome.” Centers for Disease Control and Prevention, 7 Feb. 2020, wwwn.cdc.gov/WPVHC/Nurses/Course/Slide/Unit3_11. Accessed 24 Apr. 2022.
Smith, Donna and Smith, Donald. Interview with Caroline Efird. 3 February 2019 (Y-0065). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Stratas, Nicholas. Interview with Carolina Efird. 4 January 2019 (Y-0066). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Swartz, Marvin, and Morrissey, Joseph. “Mental Health Care in North Carolina: Challenges on the Road to Reform.” North Carolina Medical Journal (Durham, N.C.), vol. 64, no. 5, Sept. 2003, pp. 205-11, https://doi.org/10.18043/ncm.64.5.205. Accessed 3 Mar. 2022.