A recent study published in the Canadian Medical Association Journal examines physicians’ views of Ontario Region academic health center procedures for transferring students in psychiatric distress to hospital emergency departments.
Findings indicate that physicians generally choose to involve the police – who often use physical restraints – during mental health transfers for pragmatic reasons or because of liability issues, despite their recognition of the potentially traumatic impact of doing so. TO DO.
Against the backdrop of rising rates of self-harm and suicidal behavior among Canadian university students, the researchers, led by Juveria Zaheer of the University of Toronto, sought to investigate current approaches used by physicians at Ontario universities. to respond to students in acute distress.
Under Ontario’s Mental Health Act, physicians who believe a student is at risk of harming themselves must complete a “Physician’s Request for Psychiatric Assessment Form 1” to order the transfer of the student to a hospital emergency room for psychiatric evaluation. Since 2014, the number of mandatory mental health transfers from Ontario universities has increased significantly, but little is known about what these transfers look like in practice. Zaheer and his co-authors explain:
“The processes of such transfers are an understudied topic, part of a larger gap in research surrounding the transport of people in mental health crisis to hospital from community points of care. There is substantial heterogeneity in transfer processes when a Form 1 is completed for students presenting to academic health clinics in Ontario. In particular, police intervention and the use of physical restraints for transfers vary from institution to institution and have been the subject of media review.”
The use of law enforcement during involuntary hospitalizations has generated debate and concern. Some healthcare professionals argue that it is necessary to ensure patient safety. However, mental health advocates have widely criticized the practice, saying the involvement of police and the use of physical restraint “are traumatic and stigmatizing, and perpetuate the criminalization of people with mental illness.” Further, the continued police violence against racially marginalized people underscores the urgent need to view police involvement in involuntary transfers as a matter of racial injustice.
In order to better understand the procedures currently in place in Ontario universities for the implementation of mental health transfers, the researchers integrated three sources of data collected from university physicians: qualitative interviews, questionnaires and institutional policy documents. .
Eleven physicians (9 family physicians and two psychiatrists) from 9 different academic health clinics in Ontario participated in semi-structured interviews. Ten participants also completed questionnaires about their demographics, training and practice experiences, and general beliefs about crisis transfer processes. In addition, institutional policy documents were provided by the administrators of 5 of the participating clinics.
Interview transcripts were qualitatively analyzed via thematic analysis, and information from questionnaires and policy documents were summarized and used to clarify clinical procedures and substantiate themes. Three main themes emerge from this analysis.
Theme 1: The police and coercion harm students
All physicians described harms associated with police involvement in transfers. Many participants further described how police involvement broke students’ trust, severed the therapeutic relationship, and deterred students from returning to the clinic for future services. A doctor said:
“People have enough trouble being in the hospital, but having to be taken in handcuffs…out of the building and loaded into a police cruiser and taken half a block away feels brutal and traumatic for the patient, and sends all the wrong messages about a benevolent and supportive environment.
Theme 2: Police intervention and use of restraint are justified based on patient considerations
Doctors expressed a common view that there are rare circumstances where police intervention is deemed clinically “necessary” based on perceived risk, such as the likelihood of a student acting violently or attempting to escape to hospitalization.
Theme 3: Transfer processes are often influenced by extramedical factors
Physicians at most clinics rationalized the use of police and constraints citing limited workforce capacity and institutional policies. Several doctors said they rely on police to escort students to hospital due to staffing shortages, workflow and liability considerations. Additionally, in 6 of the 11 clinics, official institutional policies required physicians to involve campus or city police. Once the police were called, the doctors no longer had control of the transfers and the police decided whether or not to use physical restraints, choosing to do so in most cases. One participant said:
“They [police] most of the time… 9 out of 10 times will apply handcuffs to a patient which can be a very traumatic experience. And so the discussions we’ve had with the constables about whether or not this should be done have generally come down to, “You know what, we have to respond to the highest potential risk.”
The minority of clinics offered more flexible procedures, allowing doctors to opt out of contacting the police and allowing clinic staff or mobile crisis teams to escort students to the hospital instead.
This qualitative study sheds light on how the use of law enforcement and physical restraints during mental health crisis interventions is normalized by healthcare providers. Limited resources and fears of being held accountable for patient safety perpetuate doctors’ reliance on the police. The researchers describe how this addiction contributes to a dangerous cycle of marginalization and violence:
“Police intervention and the use of restraints can be traumatic, with the death of people in crisis occurring in worst-case scenarios. People may experience fear and stigma when the police are involved and handcuffs are applied, which can breed mistrust and deter future help seeking. The potential for adverse outcomes is magnified when police are engaged in crisis mental health care, particularly for patients with intersecting systemically marginalized identities.
The authors conclude by noting the need for more research in meaningful collaboration with people with lived experience to truly understand the detrimental impact of involuntary hospital transfers and devise new strategies for responding to psychiatric crises without the police.
Chittle, A., Neilson, S., Nicoll, G. and Zaheer, J. (2022). Physicians’ perspectives on mental health emergency transfer processes from academic health clinics to hospitals in Ontario, Canada: a qualitative analysis. Canadian Medical Association Open Access Journal, ten(2), E554-E562. (Link)