(Originally published in Monday Magazine, June 10, 1999.)
An irritated neighbour, worried sibling or angry landlord could set you up for a mental health check-up. After a visit from “the team”, you could end up with fewer rights than a criminal.
THEY don’t want you to know that your neighbours, teachers and landlord can send “the team” after you. That the helpline may tip authorities to trace your number. That staff at the shelter to which you flee may help incarcerate you without trial.
They don’t want you to know, because that might hurt their chances of helping you in your time of crisis. So if you read this article, goes the argument of some of Victoria’s mental health professionals, Monday will have done you a grave disservice.
But ever since Frank Kingsley found out, he’s been convinced everyone should know.
As Kingsley tells it (names and certain details in several testimonies have been changed to preserve anonymity), his story began three nights after he was assaulted by his girlfriend’s ex-lover. The investigating police officer appeared at his door, escorting two plainclothed women. One began asking Kingsley questions. The other took notes.
“Are you suffering from stress, Mr. Kingsley?” he recalls the woman asking. “Do you take medication? Have you ever smoked marijuana?”
Kingsley says he answered casually. But when he was asked about his sex life and his relationship with his mother, he began to feel uncomfortable.
“What is today’s date?” continued the woman.
Kingsley wondered aloud why he was being asked such questions. The woman responded cryptically: “Do you have a problem with it?”
Eventually, Kingsley was told the woman and her partner were mental health professionals. They were worried he might be suffering trauma from the assault.
Kingsley says he thanked them for their concern. But he was stunned by the questions that followed.
“What’s the relationship between an apple and a banana?” asked the woman. “What’s the similarity between a canoe and a bicycle?”
“I started to get a really funny feeling that this wasn’t quite right,” Kingsley recalls now. “It sounded like they were asking questions to check on whether I was a nutcase or not, rather than worrying about me suffering from trauma and wanting to help me.”
Kingsley asked the police officer what was going on. The officer explained that his assailant had confessed, but asserted that Kingsley was dangerously mentally unstable. The two women were “assessing” Kingsley to decide whether he needed treatment.
Kingsley was flabbergasted. A 53-year-old professional, he had never been in contact with any mental health worker, and had never before been involved in a physical altercation. Was this just another way for his assailant to lash out at him?
This suggestion was greeted with silence.
“What does it mean that people who live in glass houses shouldn’t throw rocks?” continued the woman.
“It’s like you’re walking on a razor’s edge,” explains Kingsley. “Your normal reaction as a citizen, or a human being, is to get angry with this bullshit, and tell them to get the hell out of your apartment. But you’re afraid to actually get angry, because you’re sure they’ll use that against you.
“It’s degrading,” he continues. “I felt intimidated, and afraid . . . It was the fact that they could just come like that at any time, bang on your door, charge in, and possibly haul you away.”
Twenty minutes after their arrival, the three stood to leave. They indicated that they’d “check out” some of Kingsley’s answers. That was Kingsley’s first–and so far his only–visit from a local emergency mental health response team.
Psychiatric emergency response teams have existed in B.C. for well over a decade, says Vancouver General Hospital’s Dr. Dan Bilsker, a psychologist and member of a B.C. Ministry of Health-appointed group studying mental health crisis response. But as part of an international trend in “assertive community management”, says Bilsker, the use of emergency response teams and other community mental health workers to get people into early treatment is increasing.
“In the last 10 years it’s become very dominant,” says Bilsker.
In the Victoria area, the Capital Health Region’s emergency mental health services (EMHS) department oversees 15 staff that operate in two-person emergency response teams, each consisting of a community nurse and a social worker.
According to an EMHS pamphlet, the teams’ primary mandate is to aid and protect people undergoing psychiatric crises or “severe situational difficulties” who are in risk of doing harm to themselves.
For example, a mobile team should be called in, says the pamphlet, when a person expresses suicidal thoughts or exhibits more subtle symptoms of harmful behaviour, like “an inability to attend to work”.
According to their procedural manuals, the team may meet with you (with or without police alongside), talk with people who know you, attempt to solve problems or provide therapy, refer you to a community agency or mental health professional, accompany you through the admissions procedure of a psychiatric hospital, or even advise police to take you to hospital by force.
Although the EMHS contact number is “not public”, the number is widely available. Aside from police, mental health workers, family physicians and relatives of mentally ill people, many lawyers, landlords, school teachers, employers, clergy, staff at community organizations and ordinary people now have the number. Any third party can ask the team to consider visiting anyone else.
There are undoubtedly people with mental disorders who need EMHS assistance. But critics like Kingsley note that the emergency response teams can act as a mechanism to allow ordinary people to submit each other to psychiatric assessments. In turn, those assessments could lead to incarceration and treatment with drugs or electroshock under B.C.’s Mental Health Act. To Kingsley, such serious potential consequences point to a need for health units to be closely monitored.
His primary question is simple: How do teams assess who should go to hospital?
EMHS manager Nancy Panagabko refused to answer questions or to allow Monday to interview anyone involved with the emergency response teams. Even Capital Health Region spokesman Andrew Hume would answer only select questions, even when submitted in writing.
In answer to questions about psychiatric assessments, Hume pointed to the textbook collection of the Eric Martin Pavilion psychiatric hospital. In these books’ pages, Kingsley’s story of his strange interrogation unfolds as a standard “mental status examination”, cited as the most important assessment tool of the emergency mental health professional. Assessors are advised to consider factors like whether the interviewee has the potential to commit homicide or suicide, has good reasons to explain wearing “bizarre” clothing, is “normally responsive to cues”, or “laughs appropriately”.
EMHS training documents also include a “Crisis Triage Rating Scale”. Using this system, even if you have no notions of doing harm to yourself or others, merely refusing to cooperate with mental health professionals and having limited family or friend support would place you in the category of “hospital is indicated”.
As B.C.’s approach to mental health care becomes increasingly aggressive, more and more ordinary people like Kingsley are being submitted to such assessments in unexpected situations. Every year, thousands of Victorians come into contact with organizations that use EMHS regularly, and according to EMHS statistics, mental health teams visit over 200 Victorians every month.
Victims of “people crimes” like sexual assault, home burglaries or even auto accidents can expect calls or visits from volunteers with Greater Victoria Victim Services. According to Marlline Halisheff, the director of the non-profit society, volunteers arrive at crime scenes by listening to police radio, and police routinely pass them names, addresses, crime summaries and other confidential details.
Although volunteers come to give victims emotional support, if a person needs more support “than we’re trained to handle”, says Halisheff, a call may be made to EMHS.
Representatives from most of Victoria’s emergency shelters say they may call EMHS when someone overstretches the overworked staff’s ability to provide care–examples given by shelter staff ranged from people hallucinating and not eating to those acting in ways that were “not congruent with normal behaviour”.
The NEED Crisis and Information Line’s use of emergency mental health response teams has increased fourfold since 1992, to about 35 times monthly in 1997-98. But, assures clinical director Linda Stanton, “We never refer to emergency mental health services without the caller’s permission.” She acknowledges, though, that the caller isn’t always the person whom EMHS might come to assess.
Several mental health patients and professionals also expressed concern about calls to the NEED Crisis line apparently being traced, and police arriving and taking callers to the psychiatric hospital against their wills.
Asked about these concerns, Stanton points out that the NEED Crisis line is also a suicide prevention centre. “We are highly trained here to do crisis intervention work, where our volunteers make a risk assessment and we do whatever we can to ensure that people remain safe. And that may involve contacting the police.”
Stanton explains that out of the 15,896 calls to the crisis line last year, around 500 involved referrals to outside agencies like EMHS and poison control centres–and of those, only a small number involved call tracing and police action. (In subsequent investigations, Monday discovered that many “anonymous” crisis lines across North America have policies and procedures in place to have certain calls traced to facilitate police interventions, but most news media have voluntarily agreed not to publicize this fact.)
While people experiencing a serious problem or calling for help may be surprised to receive a visit from police or “the team”, others say they were surprised that anyone thought they were in an emergency situation at all.
Recently divorced and laid off at the age of 35, Joan Mackay became depressed. She wasn’t suicidal, she says, but had been finding it challenging to get out of bed. Meanwhile, longstanding conflicts between her and her father were intensifying.
Earlier this year, two people arrived at her door with two policemen, she says. Always an “anxious” person, Joan admits she backed away. A male officer then clutched her arm while a woman introduced herself as a social worker who wanted to talk. Confused and afraid, Joan refused.
Joan was promptly taken to the Royal Jubilee Hospital emergency ward and then transferred to the Eric Martin Pavilion. Her purse was searched, she says, her requests to contact a lawyer were denied, and no one informed her of her rights. She says that despite complaining about being kept against her will, she was not informed that a complaints process was available to her.
Finally, she says, she came up with a strategy. “I just thought, if I remain calm and go along with this, this will all end at some point.”
Joan says a psychiatrist informed her that her father had contacted EMHS and the Eric Martin Pavilion and had described Joan as threatening and suicidal. For her part, Joan describes her elderly father as an easily frustrated, domineering man who has “lost some of his reasoning skills and memory”. She believes his call to EMHS was a way of getting back at her for cruel things she’d said in the heat of argument. What likely played a significant role in Joan’s release from hospital four weeks later was that another close relative presented herself to hospital staff and backed up Joan’s side of the story.
The experience has left indelible scars on Joan.
“I want to cry because it’s so horrible,” she says of how easily she was involuntarily committed and treated with medications, apparently as a result of a family feud and an interview with a psychiatrist which she says was conducted while she was still in “utter shock”.
Her picture of our society has changed dramatically, too. “Where do you separate the medical team and the police?” she wonders. “I find it very frightening that our government has encouraged this.”
In fact, says Staff Sergeant John Smith of the Victoria police department, the police and EMHS do share many common goals and a common complaint about the mental health system: that not enough people are being kept in hospital.
“There seems to be some sort of, let’s say, a professional difference of opinion,” says Smith, referring to people who’ve been brought in by police and/or EMHS and promptly sent home by hospital doctors.
Smith, the department’s emergency mental health liaison, acknowledges that the bulk of Mental Health Act arrests involve “a big grey area” of interpretation. Often, neighbours will complain about someone’s all-night banging or unhygienic living conditions and police will “err on the side of caution” and take the person to a hospital for a psychiatric assessment, says Smith.
Most people and organizations interviewed by Monday said the most common cause for contacting EMHS is when they observe people whose behaviour is so far outside social norms that they seem to be placing themselves in danger.
Rose Henry, the director of the Victoria Street Community Association, points out that a person can become a “danger to themselves or others” merely by being extremely dysfunctional in our fast-paced, uncompassionate and dangerous society. Henry sympathizes, but has a ready response for those occasional people who have angrily blamed her for their negative experiences after her call to EMHS helped put them in hospital: “That’s better than being found in a back alley dead.”
Henry’s remark highlights something Brett Haughian, senior paralegal for the Community Legal Assistance Society’s Mental Health Law Program, has observed–that the tactics of forced psychiatry are more often used to help control people’s behaviour than to help improve how patients themselves feel.
“That’s definitely the trend,” says Haughian. “There seems to be more emphasis on trying to categorize behaviour and get it off the streets.”
As the Victoria police acknowledge, when such relatively harmless people are taken to hospital there is no requirement to inform them of their rights. The reason? The person isn’t being charged with an offense. Police and EMHS are simply trying to help.
All of which raises the question: What are a person’s rights before his or her life becomes subject to everyone else’s “differences of opinion” about his or her behaviour?
Haughian explains that the mental health unit that might arrive at your door has broad powers. Based on their own observations or information received from a third party, he says, police and EMHS together can enter your home, examine you, or take you to a psychiatrist for an examination. If you refuse to talk, states Haughian, your reticence could be used as part of the police or EMHS assessment, or even as part of the hospital psychiatrist’s diagnosis that gets you incarcerated.
“One of the problems is, there’s no definition of what an ‘examination’ is,” says Haughian. “Examination is a pretty wide open exercise.”
If society intends to provide such exceptional powers to control “unusual” behaviour or expression, and ultimately to impose psychiatric treatment onto an ever-wider variety of people, it seems important to make sure there’s solid science underlying diagnosis and treatment of mental disorders.
Unfortunately, opinion differs widely even on what constitutes a psychiatric “examination”. In fact, the entire field of mental health science and law is surrounded by a vast maze of hazy issues that provide ample room for error when applied by frontline workers.
For example, Stanton notes that the NEED Crisis line is certified by the American Association of Suicidology, and that volunteers receive six hours of training in “risk assessment”. Nevertheless, Martha, a woman who takes psychiatric medication and admits calling the crisis line often to talk about her suicidal feelings, is one person who was less than impressed with a particular crisis line volunteer’s perspicacity.
“I said I was going to commit suicide in the millennium. Not tonight, in the millennium,” says Martha. “But the police and ambulance showed up. [The volunteer] must have been a rookie or something.”
Meanwhile, a large body of evidence suggests professional psychiatric assessments and predictions of dangerous behaviour frequently prove to be inaccurate–in some cases, no more accurate than the guesses of rank amateurs.
In Stanford University psychologist David Rosenhan’s famous 1973 study “On Being Sane in Insane Places”, staff at 12 different psychiatric hospitals failed to distinguish “normal” people from other patients. Similarly, in her 1998 book Manufacturing Victims, psychologist Dr. Tana Dineen points out that the standard clinicians’ bible, the Diagnostic and Statistical Manual of Mental Disorders, “pathologizes” such behaviours as lovesickness, sleepwalking and computer addiction.
According to Principles and Practice of Emergency Medicine–a 1992 textbook in the Eric Martin Pavilion’s own library–easily detected ailments like nutritional deficiencies, infections and cardiovascular diseases have been shown to be the causes of the mental disorders of up to 30% of psychiatric hospital emergency patients. These causes usually go undetected, the text says, because less than 10% of psychiatrists ever do physical examinations.
And in 1997, Dr. Grant Harris and Dr. Marnie Rice of Ontario’s Mental Health Centre published an overview of the scientific literature on predicting violent behaviour in mental patients. The article states that psychiatric predictions of violent behaviour “are wrong twice as often as they are right”. The researchers add that “[n]o evidence has been found” to suggest that psychiatrists’ judgments are better than those of laypersons in predicting violent behaviour.
When asked in writing how they respond to such expert criticisms, spokesman Hume replied that the Capital Health Region would not respond to “unsubstantiated allegations”.
But Dr. Bilsker of Vancouver General Hospital’s psychiatric assessment unit readily confirms the general criticisms.
Bilsker explains that his health ministry crisis response working group has been carrying out extensive research to ensure that B.C.’s emergency mental health practices are “evidence-based”.
Mental health professionals, concludes Bilsker, aren’t “terribly accurate” in their predictions about the likelihood of patients doing harm to themselves or others over the long term. “No one has that ability,” he says. He feels professional predictions of risks over several days are “pretty good”, but admits no studies back up that belief.
Even if there may be short term benefits, can we feel confident about the long term benefits of subjecting depressed or emotionally volatile people to detention and forced treatment?
“There’s always a trade-off, and I know of no way around that trade-off,” he concedes.
“There’s an unrealistic notion on the part of the public, and even on the part of some mental health practitioners, about what treatments can do, and about the limitations of treatments,” Bilsker says.
For this reason, his working group will be recommending a “de-emphasizing of hospitals”. According to Bilsker, community supports, safe houses and non-medical therapies have been shown to be as effective as psychiatric treatment in helping people manage many kinds of acute mental problems.
It sounds constructive. But in fact, B.C. is undergoing unprecedented polarization between those who support individual rights, community agencies and non-medical approaches, and those who advocate greater state control through forced medication.
In 1994, B.C. ombudsman Dulcie McCallum launched the first ever independent investigation of a major Canadian psychiatric institution. She found “systemic” disregard for legitimate patient concerns at Vancouver’s Riverview hospital. She also strongly endorsed the Mental Health Law Program service of providing involuntarily hospitalized patients with free, automatic access to independent rights advice. According to Haughian, most B.C. hospitals have refused to allow the service and the B.C. government has refused to mandate it.
Meanwhile, legal advocates, civil rights groups and many community agencies vehemently protested last year’s amendments to B.C.’s Mental Health Act, some arguing the expanded criteria for involuntary treatment could apply to virtually anyone.
Proponents of forced psychiatry argue tougher laws are needed because many disordered people aren’t capable of competent decisions. In response, Haughian points out that, unlike in Ontario, B.C.’s Mental Health Act now authorizes treating people against their wills even when they’re still deemed competent.
Alex Berland, interim director of the B.C. health ministry’s adult mental health division, clarifies the government’s objective: to help patients live in their own homes while mobile caseworkers ensure those people stay on medications. And since psychiatric treatments sometimes help manage yet “almost never cure” severe mental disorders, the new plan is to use organizations like EMHS to help identify people in the early stages of illness and then intervene with drugs in the hope that disorders can be prevented from developing.
Questioned about evidence of the inaccuracy of diagnostic tools, Berland disagrees and points to this year’s Canadian Mental Health Association early intervention study–a study that, in fact, states that “nearly half of participants received an incorrect diagnosis”.
Nevertheless, Berland declares that “teams and teams” of mental health workers will be involved in the growing “assertive community treatment” project.
For now, it seems, Victorians will have to live with what Bilsker refers to as the “trade-off”.
On the one hand, some people experiencing psychological problems will be aided by forced interventions–people like Anna, who speaks for the many people helped by psychiatric treatment. Found rambling and shouting in the streets, Anna was escorted–protesting all the way–to hospital. Today, she is on medication and functioning well.
“For me, [EMHS] was a lifesaver,” she says.
But others will have to live with the other side of the trade-off: living in a society where experiencing or even just talking about emotional difficulties may expose you to the risk of incarceration or forced treatment.
Both Sandy Merriman House shelter manager Chris Downing and Victoria Street Community Association director Rose Henry observe that, even though teams tend to be compassionate and can often “ground” people and help keep them out of hospital, most people who’ve been in hospital before have negative reactions when told EMHS has been called.
“It takes quite a bit of encouragement to keep them on site until the team arrives,” states Henry.
After her own initiation to B.C.’s mental health system, Joan Mackay sympathizes with such reactions. “If I ever get suicidal,” she says, “then I’m never going to tell anyone.”