Recently, Dr. Margie Balfour joined the Crisis Jam to discuss one of the most pressing issues in crisis care: voluntary versus involuntary admissions. Dr. Balfour, Chief of Quality and Clinical Innovation at Connections Health Solutions took the position that crisis facilities should accept involuntary individuals, while Travis Atkinson, Director of Clinical and Crisis Services at TBD Solutions, presented the opposing view, arguing that crisis care should focus on voluntary services. 

The case for involuntary crisis admissions 

Dr. Balfour highlighted the critical need for crisis facilities that can accept involuntary individuals. She pointed out that, in many communities, first responders—police, mobile crisis teams, and EMS—encounter individuals in acute crisis who may require involuntary commitment due to agitation, potential violence, or being a danger to themselves or others. Without a crisis center capable of managing these individuals, the default options are often jail or emergency rooms, both of which present significant challenges. 

"Jail is bad to bring people for a behavioral health crisis. I think we all agree," Dr. Balfour stated. "The default is often the emergency room in most communities, but what happens in the ER is not great for people experiencing behavioral health crises." She emphasized that fewer than half of emergency rooms in the U.S. offer psychiatric services, which means individuals receive little to no treatment while waiting for extended periods. 

Dr. Balfour explained that crisis centers specifically designed to manage involuntary individuals provide a specialized, therapeutic environment with psychiatrists, nurses, social workers, and peer specialists. "You need a crisis center that can take these folks," she said. "In our Tucson facility, we found that 60% of involuntary patients engaged with treatment and either improved or voluntarily continued their care." 

The counterpoint: a case against involuntary crisis admissions 

Travis Atkinson argued that crisis facilities should not be required to accept all referrals in order to be considered a crisis service. He used the analogy of shoes—not one size fits all. "We often take for granted how good it feels when our shoes fit, but we’re building our crisis services on a faulty assumption that they should be like blankets—one size fits all—when instead, they should be right-sized," Atkinson said. 

Atkinson highlighted that historically, alternative crisis services such as mobile teams, 988 centers, crisis stabilization units, and peer respite programs were created to provide a different experience from traditional institutional settings. "Just like an artist relates to their self-portrait, a crisis should be defined by the person experiencing it," he argued. "Respecting these parameters preserves agency, dignity, and choice throughout a treatment experience." 

He also pointed to international examples, such as Trieste, Italy, where a community-based approach to mental health has been highly effective. "In Trieste, they take a very intentional approach with their housing, employment, and inclusion. Only 30% of their Community Mental Health clients need to take medications, and they have just four inpatient beds for a population of 200,000—and they’re rarely full." 

Finding the right balance 

The debate underscored the need for a crisis system that accommodates both involuntary and voluntary care. In communities where crisis centers are voluntary-only, individuals requiring higher levels of care often end up in emergency rooms or jails, limiting their ability to receive appropriate treatment. However, over-reliance on locked facilities can lead to unnecessary restrictions on personal freedom and increased trauma. 

Dr. Balfour and Atkinson both emphasized that effective crisis systems require different levels of care. "You want a higher resolution crisis system where you have different levels of care for the right population," Dr. Balfour noted. "If you don’t have a crisis center that can take involuntary individuals, they’re going to default to other levels of care—so your sickest people, the ones most in need of specialized care, are excluded." 

Within facilities that manage both voluntary and involuntary cases, the focus should be on minimizing trauma, reducing harm, and ensuring that care remains person-centered rather than security-driven. Connections centers specialize in treating high-acuity populations without security guards, instead investing in well-trained clinical staff and peer specialists to create a safer and more therapeutic environment. 

From a policy perspective, SAMHSA’s guidelines provide a foundation for defining crisis care levels and standardizing reimbursement structures. By clearly distinguishing high-intensity crisis centers from other crisis models, communities can build more effective and financially sustainable crisis systems. 

SOURCE: Crisis facilities should receive voluntary & involuntary referrals - Ep 206 | 988 Crisis Jam