Chances of police involvement in the care of a student seeking help for their on-campus mental health at a University of Ontario health clinic depend on which university they attend, according to a new qualitative CAMH-led study published today in the journal. Open CMAJ.
This study is believed to be the first in the world to conduct in-depth interviews with clinicians to examine policies and processes for transferring students with mental health emergencies from university clinics to hospital. Investigators have found that some Ontario universities mandate the use of police restraints in all circumstances when students need emergency care at a mental health hospital, while others have policies that handcuffs are used only in rare cases as a last resort.
“We wanted to identify university policies that facilitated dignified transportation to the hospital from campus for students who needed emergency mental health care. We hoped that such policies would serve as models for other universities,” said lead author Dr. Andrea Chettle, a family physician who worked in a health clinic. college. “We learned that in some universities, handcuffs are used every time. It is usual to take students to the hospital shackled in all cases.”
This work is particularly timely, as mental illness among Canadian post-secondary students and mental health transfers is on the rise when a student with a mental health crisis is transported from university health clinics to hospital for psychiatric evaluation and/or emergency care ー become more common.
The authors interviewed 11 physicians at nine university health clinics in Ontario between July 2018 and January 2019. The interviews were confidential and the clinics were not designated to allow physicians to speak openly about hospital transfer policies for students with mental health emergencies. In five of these clinics, the police were always called to help when a student needed to be taken to hospital. In two of these clinics, it was police policy to routinely use handcuffs while taking students to the hospital.
Doctors surveyed in clinics where handcuffing of students was common expressed concerns that doing so would traumatize students in a way that could discourage them from seeking mental health support in the future.
“To be handcuffed and loaded into a police cruiser sounds brutal and painful to the patient and sends all the wrong messages about a caring and supportive environment,” one interviewee said.
This study is the third collaboration of co-authors Dr. Andrea Chettle, MD, emergency department psychiatrist at CAMH, Geoffrey Zuhair and Shane Nelson, MD, a student health clinic, examine mental health transfer policies at Ontario universities.
Their first paper identified police handcuffing of students with mental disorders as an area of concern. The second paper reviewed the policies and processes for transferring people with a mental health crisis from community clinical settings to hospital. This latest study examined the decision to engage the police and the use of handcuffs during mental health transfers, and alternatives to this practice.
The researchers found that police involvement and use of restraints when students need to be transported to hospital for psychological evaluation is often due to non-clinical factors, such as an understanding of staff roles and responsibilities, human resource constraints, and staffing implications of long wait times in the emergency department.
“Before I was in the system, I didn’t realize just how intertwined police are with mental health,” said university student and study contributor Gina Nicole, who has experienced mental illness including being taken by police to hospital for evaluation. “I was really frustrated and felt defeated and weak. It made me feel like I was doing something wrong just because I wasn’t feeling well and I felt like a criminal because of it.”
The authors concluded that routine police intervention in students’ mental health transfers to hospital is harmful. They suggest engaging the police only in rare circumstances when the risk of a student escaping or becoming violent during transportation to hospital is high. They recommend developing provincial-level policies to reduce police use of restraints during mental health transfers from University of Ontario clinics in collaboration with university administrations, municipal and regional governments, hospitals, police departments, and people with a living experience of mental illness.
As an emergency department psychiatrist, I see people on the worst days of their lives. People with suicidal thoughts. People with psychosis. They may be afraid. They may have a shock. They may not want to be there. Likewise, in university settings, we have people who feign distress and crisis in a myriad of different ways, including students who experience racism and have had experiences of persecution and negative interactions with the police. Although we can’t say we never need to use constraints, they should be used rarely and wisely as a last resort. It should not be default, because this is stigmatizing and intimidating. We need to be aware of trauma, be safe and limit self-control, just as we need to do in all healthcare settings.. “
Dr. Geoffrey Zuhair, first author of the study and a psychiatrist in the Emergency Department, Center for Addiction and Mental Health
Dr. Shettle added that she hopes that public debate about the role of police on campus will persuade universities to examine their policies and operations for students experiencing a mental health crisis. She notes that following previous work by she and her colleagues studying the practice of routine police engagement and the routine use of handcuffs at the University of Guelph, a more flexible procedure for hospital transfers has been developed. At the same time, changes in police policies allowed for discretionary use of restraints when police were involved in transfers.
“I think we’re seeing society move more broadly away from police involvement in mental health care,” Dr. Chettle said. “There are some pilot projects being implemented that are non-conditional models of mental health crisis care. I hope that’s where we’re headed.”
Center for addiction and mental health
Shettle, A.; and others. (2022) Physicians’ perspectives on emergency mental health transfers from university health clinics to hospitals in Ontario, Canada: a qualitative analysis. Open CMAJ. doi.org/10.9778/cmajo.20210135