This is the third story in a six-part series on mental health and substance use in Columbus County. Today, the News Reporter and Scalawag examine how people dealing with behavioral health issues end up interacting with law enforcement. On Monday, Part IV will examine hospitals and the health care system, and look at the influx of mental health patients in emergency rooms.

From his 16 years as a sheriff's deputy, one case still haunts Mack Ward. He was dispatched for an involuntary commitment of a young man in the midst of a mental health crisis.

"He was very violent," Ward recalls. "He had assaulted his mother, and as the thing unfolded, he moved from one part of the county to another in an automobile. And at the very end of it, when his automobile was disabled, I saw him from some distance shoot himself in the head."

"I watched this kid commit suicide. Absolutely nothing I could do. And to this day, I have that horrific picture in my mind."

Involuntary commitments—IVCs, to those who deal with them regularly—are something like the civil equivalent of warrants. Someone, usually a family member or a medical professional, petitions magistrates to have a person taken into custody and transported to an appropriate mental health facility for treatment.

After his time with the sheriff's office, Ward became a magistrate. Appointed by the state to countywide jurisdictions, magistrates also decide whether to issue warrants in criminal cases. In the 16 years Ward served as a magistrate, 1996 to 2012, North Carolina state policy pivoted away from public mental health agencies toward a privatized model.

Ward describes the change in the volume of IVCs over his time as a magistrate: "I just saw this uptick in it. I mean, it was just more and more and more."

"There was a sense that we could solve all these problems by putting it in the hands of private practices. Privatization of mental health care ain't working," Ward says.

Part of that is the changing nature of the issues that police are facing. With public mental health care decreasing and IVCs on the upswing in recent years, law enforcement officers are now de facto first responders for many experiencing mental health crises.

The increasing contact of law enforcement with the mentally ill both strains resources and puts those in crisis into contact with police before—or instead of—contact with the mental health practitioners they need to see.

"Our system was not created for ER and police officers to be the first line of triage for people with mental illness," says Nicholle Karim, interim executive director of the National Alliance on Mental Illness-North Carolina. "But that is what we have. And part of that is from the deinstitutionalization movement, and from not having good community care."

IVCs are issued during crisis situations, only when a person is a danger to himself or to others. The deputies who carry out the order have some training in dealing with behavioral health issues, but it is mostly focused on the safety of all parties involved.

"It's good training," says Sgt. Jason Durdle of the Columbus County Sheriff's Office. "But every person is different, everything they have going on is different—there's no training but being a doctor or actually doing it for a while that could possibly prepare you."

When an IVC goes smoothly, patients are ferried to hospital emergency rooms, where they wait for beds in psychiatric hospitals to open up. Public beds in North Carolina have grown scarce since the closing of Raleigh's Dorothea Dix Psychiatric Hospital in 2012, so that wait often lasts for days.

When a bed is found, sheriff's deputies are the ones to take the patient to that bed. The state's three hospitals are located in Goldsboro in the east, Butner in the Piedmont, and Morganton in the west. But the state pays for psychiatric beds in certain local hospitals statewide, too. Sgt. Durdle estimates that trips to Charlotte are most common, with a deputy making one every couple of weeks. Sometimes, patients from Columbus County travel as far as Asheville.

"If I didn't have to send officers just about daily to different places in the state to carry mental health people, I could focus on a lot of other stuff," says Columbus County Sheriff Lewis Hatcher.

"But, by the same token, wouldn't it be great if there was somewhere here that someone could walk in to and just say, 'Hey, I need some help'?"

"We need some local professionals, or some way to get these people into facilities quicker, rather than just staying in an emergency room. It's just sad," Ward echoes.

"I'm no bleeding heart liberal," he hastens to add. "But that stuff really galls me."

Locked Up

But the increasing reliance on law enforcement to deal with those experiencing behavioral health crises is much more than a problem for law enforcement. Difficult interactions with officers can exacerbate mental health issues. So can jail. Often, those in psychiatric crisis are not IVC'd, but instead commit a petty crime and end up behind bars.

"Most of the time it's not someone that's charged with something real, real serious," says Sheriff Hatcher. "They'll go to a store, and they'll ask people for money. Or the storeowner will say, 'You're trespassing and you need to leave.' And if they don't leave, then someone goes, 'Arrest this person, bring 'em out here.'"

Those sorts of petty crime—loitering, panhandling—coincide with homelessness. In 2014, the North Carolina Coalition to End Homelessness calculated that 24 percent of North Carolina's estimated 11,440 homeless people had a serious mental illnesses, a much higher figure than that of the general population, which the national Substance Abuse and Mental Health Services Administration pegs at about one out of every 20 North Carolinians. Thirty-one percent of the state's homeless, according to the same N.C. Coalition data, had substance use disorder.

Once in jail, patients are unlikely to get adequate mental health treatment, as Hatcher is quick to admit. "We have nurses over here at the jail, but to actually deal with mental health issues? No."

"That is not where they need to be," he says. "They need to be in a facility where someone can help them and they can get some kind of treatment."

And those with mental health issues are at increased risk of solitary confinement, which law enforcement officers call "segregation." "Segregation over there is not to punish anyone," says Hatcher. "People have mental health issues. And people will take advantage of them, and people will hurt them, and they can hurt people too. So we segregate them, we separate them, for their safety—and the other inmates in there, for their safety too."

Segregation, though, is particularly hard on people with mental illnesses, explains Karim. "For people who have a mental illness, going into solitary confinement absolutely exacerbates their symptoms. And if it exacerbates their mental health symptoms, people generally stay in solitary for longer, because to someone who doesn't know the symptoms of mental illness, they see it as acting out," she says.

"Even people who are healthy, who do not have a mental illness, when they enter solitary and if they stay for a period of time, they begin to develop mental health symptoms."

Before Crisis

IVCs are ordered, by definition, during moments of crisis.

"Part of the problem in North Carolina is we've created a crisis system," says Karim. "So people are getting to the point—I like to use the example of diabetes. They're going into a diabetic coma. And that's when we're starting to get involved, is when our system is really responsive. But the response isn't right.

"Sitting in an ER, waiting to get treatment—that's not treatment."

Waiting until such times to address mental health issues ensures that they are costlier and more painful. They can also be deadly, as Aaron Cox knows. His sister Karen was a successful basketball player whose playing career took her throughout the Southeast. Once away on her own, somewhere along the way, she began acting strange.

"It's almost like someone who's addicted to drugs," Aaron says. "People start having things going on, feeling weird, and the family doesn't notice their psychosis until later."

Karen was eventually diagnosed with schizophrenia. "It was hard to get help initially," Aaron says. "She hadn't communicated any threat, she hadn't hurt anybody, she hadn't hurt herself. She was living, she was working, she was taking care of herself."

Eventually Karen's condition worsened. She became distant from her siblings and took unexplained multi-day trips. Aaron recalls getting a call from tiny Coats, North Carolina after she had been missing for three days. When he drove up, he found that she had stopped in a gas station to fix her carburetor and just stayed in the parking lot.

In May 2016, when Aaron went to visit Karen in South Carolina, she spoke through the door to him and would not let him in the house. He told his brother and sister about it, and they responded, "She does that sometimes."

"Not to me, she doesn't!" he said. The following day, Aaron went to the magistrate for an IVC, and the police escorted her to a facility in South Carolina. There, doctors found a huge growth on her chest. "The doctors thought it was breast cancer," Cox recalls. "They said it was the worst they had ever seen." But Karen refused tests or treatment. She was sent home.

Soon, wracked by pain, she accepted medical attention. Doctors found she had stage four breast cancer, which had spread to her ovaries. But at that point it was too late. She passed away before the year was out.

"When she was on her medications, she was manageable," says Cox. "I think if we had gotten early intervention, she might still be alive."

Photo of Sgt. Jason Durdle of the Columbus County Sheriff's Office.

Rethinking Tactics

Aaron Cox found the mental health care system difficult to navigate despite his great familiarity with it: He, too, worked as a magistrate for years. Before that, he served as a highway patrolman in North Carolina and trained correctional officers for the federal Department of Justice. Now he teaches at Southeastern Community College in Columbus County.

Between his experience with his sister and his professional experience, Cox has grown to see law enforcement in a new light. "Policing is really a part of social work," he says.
Cox sees a connection between mental health issues and opioid abuse in Columbus County. "In both mental health and with opioids, people start to feel that they are different, there's no help for them, they don't know where to go. Even if the places are out there, they don't know how to access them. So they feel isolated, they feel depressed. And they start taking narcotics to self-medicate."

"Right now it's opiates," Cox says, "but if I had a wand to wave away opiates, I guarantee you something would take its place. People are always going to use drugs."
Cox, who was a law officer in the 80s and 90s, compares the response to the opioid epidemic with that to crack cocaine. Like many pundits, he believes that the official response to this drug wave has been more empathetic.

"There are people who are saying it's a racial response," Cox says. "Because we didn't have the same response to crack. And crack didn't discriminate either: race, sex, gender." But because crack was seen as a Black drug, and opioids as a white drug, there is now more talk of "treatment" and less emphasis on locking users away.

Opioid use is a multi-hued phenomenon. Nationally, as opioid abuse rates spiked, overdose mortality rates increased in the Black population by 63 percent from 1999 to 2015, according to the Centers for Disease Control—less than the 3.5-fold increase in the white community, but still quite a jump. The increase was nearly as high in the Hispanic population: 43 percent. And Native Americans have higher death rates from opioid use than any other race.

Nearly everyone The News Reporter and Scalawag spoke with for this series emphasized that opioid abuse was a crisis without social boundaries. Insofar as substance abuse is intertwined with mental health issues and poverty, existing disparities in wealth and access affect the treatment and attention that people receive.

"When white folks have a cold, Black folks get pneumonia," says Andy Anderson, a service provider for patients with intellectual disabilities at Community Innovations in Columbus County. "That's just multiple factors of economics, and social disparities and educational disparities that exacerbate anything that you do have. So you just don't have the support systems, whatever challenge you have as an African American usually, or in the impoverished community—sometimes those are not synonymous in Columbus County, but a lot of times they are."

In comparing the official response to the crack and opioid epidemics, Cox sees other factors at work, too. "I think we've learned things from the past," he says. "And the response is better this time."

Alongside Durdle one night in late autumn, The News Reporter and Scalawag rode to a house near the Bladen County line where someone had called in the theft of her pocketbook. When he arrived, the caller told Durdle that the pocketbook in fact remained, but her pill bottle had been stolen.

Durdle explains that people make such calls in hopes of a police report allowing them to refill their prescriptions. He had visited the woman before for an analogous complaint, and expected to be back soon. He refused to take a police report, but spoke with her at length before driving off. Nobody got in trouble, but no real help was offered either.

"Community policing is difficult to do the right way. I think that's the reason there's a lot of pushback from the old guard," Cox says.

But if it is possible anywhere, Columbus County is fertile ground. "People know one another," Cox says. "It's rich and ripe for community policing, in a way that's more difficult in a big city."

"The easy part is seeing someone make the offense, arresting them and taking them in. But people have all types of issues that are going on in their lives. So we've got to try to get past the initial issue to find out why."

Sammy Feldblum studies geography at UCLA and reports across the southern half of the United States.