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For most people, getting treatment for mental illness involves booking an appointment with a physician, reaching out for support and perhaps taking medication. But in mental health crises or emergencies, help may be received under circumstances that are considerably more chaotic. Whether the situation is defined as a "crisis" or an "emergency," it is important that people with mental illness can receive help in a way that is acceptable to them and that avoids, as much as possible, traumatizing an already-distressed individual.
BC's Emergency Mental Health Manual explains the relationship between these two terms, saying that a mental health crisis is "a serious disruption of the individual's baseline level of functioning, such that coping strategies are inadequate to restore (psychological) equilibrium. It is an emotionally significant event in which there may have been a turning point for better or worse." The Manual goes on to say that a crisis may or may not represent a psychiatric emergency, which "…impl(ies) danger of serious physical harm or life-threatening danger."
In other words, a crisis is a situation in which outside help is needed, and it may or may not involve a situation that could be dangerous to the individual or those around him or her. When a mental health crisis exists, it is important to intervene before the situation evolves into a full-fledged emergency.
In a mental health crisis or emergency, the individual or his or her family should first contact community support networks such as the local mental health emergency team, mental health centre or family physician. Calling the police may also be an option after these other options have been tried, or if no other option is available. However, it should be anticipated that the presence of police could intensify the fear and stress of the person experiencing a mental health emergency, qualitative research suggests. "Some people are dangerous, but a softer approach rather than strong-arm tactics would reduce the terrible amount of fear," said one participant in a series of community consultations held by the Canadian Mental Health Association.
In some parts of the province, however, police are specially trained to intervene, in collaboration with local mental health emergency services (e.g. Car 87), and are dressed in plain clothes, a strategy which can make police involvement less threatening for the person with mental illness and the family. Police are increasingly making use of non-violent forms of crisis intervention, and are making use of non-lethal tools such as TASER guns, in situations which have escalated to the point where non-violent crisis intervention is not possible. TASER guns require extensive training to employ effectively and should only be used after non-violent forms of intervention have been considered.
The criteria for involuntarily detaining a person—that is, against their will—for psychiatric assessment and committal to an institution vary from province to province. In BC, most of the circumstances in which individual rights may be waived because of mental disorder are covered in the provincial Mental Health Act (Bill 22) which was amended in November 1999.
Section 28 of the revised Mental Health Act gives police responsibility to take a person into custody who is "acting in a manner likely to endanger his or her own safety or that of others and is apparently suffering from mental disorder." The decision to detain someone can be made based on the officers' observations or information provided to them by other people.
The police may take the person immediately to a physician who determines whether the person is mentally disordered and meets the criteria of "dangerousness" (risk of self-harm or harm to others) or "deterioration" (a past pattern of mental and physical deterioration that leads to serious impairment).
On the certificate of the physician, the person may be taken to a psychiatric facility and detained for an assessment period of up to 48 hours; otherwise, if judged not to meet the criteria, the individual must be released. During the assessment period, another physician must complete a second certificate stating whether the person meets the "dangerousness" or "deterioration" criteria for admission to a psychiatric facility.
The Act states that once a person is admitted to a psychiatric facility, treatment authorized by the director is considered to be given with the consent of the patient. An amendment to the Act has added that a person admitted involuntarily (or someone on their behalf) has the right to request a second medical opinion on whether or not the treatment they are being given is suitable. In the end, it remains up to the director of the facility to determine if a person's treatment should be changed.
When considering how to respond to mental health crises or emergencies it must be remembered that comprehensive community mental health services—such as housing, case management, early intervention services, and crisis response systems/psychiatric emergency services—could help prevent psychiatric emergencies from developing in the first place.
As part of the Mental Health and Addictions Reform Initiative, BC is in the process of developing a comprehensive community mental health system, including crisis response systems. The components of such as system should involve crisis lines, mobile crisis outreach (such as Car 87), walk-in crisis stabilization services, community residential crisis stabilization units, as well as hospital-based emergency services.
Community supports such as these, and access to quality services around the clock, could act as the first line of defense against the suffering caused by relapse and untreated mental illness. The need for 24-hour crisis lines and community supports is especially acute in smaller communities; such services would go a long way in reducing the number of mental health crises, and the number of mental health emergencies that require hospitalization.
Mental health policies need to focus on building trust and rapport between people with mental health needs and service providers in the community. This would encourage individuals with acute symptoms of mental illness to seek help early on, thus reducing the risk of the problem developing into a mental health emergency.
Comprehensive approaches to community support also include peer-based support services, opportunities to participate in the workforce and policies that treat people with mental illness as valued and contributing members of society. Initial research suggests that people find these services more helpful than any other form of intervention.
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Overdose: What to Do
An overdose occurs when a person consumes more drugs than their body can safely handle. These drugs could be illegal drugs such as heroin, or legally prescribed or over the counter medications.
Recognizing An Overdose
Depressants:
Moderate: uncontrollable nodding, inability to focus their eyes, excessive drooling, pale skin colour, incoherent speech.
Serious: Awake but unable to talk, persons body is very limp, erratic or very shallow breathing, excessive vomiting.
Severe: Unconscious, blue skin, person might not be breathing, can't find a pulse or it's shallow or erratic, choking or gurgling sounds, lying in their vomit.
Stimulants:
Moderate: incoherent speech, extreme paranoia, pale skin colour, jaw or teeth clenching, aggressiveness, minor shakes, excessive sweating, clammy skin, very rapid pulse.
Serious: inability to focus eyes, vomiting, foaming at the mouth, pressure or tightness of the chest, unable to talk, unable to walk, erratic pulse and violent actions.
seizures, unconsciousness, choking or gurgling sounds, not breathing, no pulse.
What To Do
Call 911 immediately: tell them the facts and symptoms.
Check that the person's airway is clear – if their fingertips, mouth, lips, or gums turn bluish or dark, they are not breathing sufficiently. Tilt their chin up and head back, straighten the airway, pinch their nose hut, form a tight seal of your mouth on theirs and give them two quick breaths every five seconds.
Once the immediate crisis has passed, consider whether the overdose may have been a suicide attempt, or the result of a substance use problem. Intervening to address these issues may avert future crises.
How Families Can Help in a Mental Health Emergency
When an individual is at risk of self-harm or harm to others or is experiencing mental or physical deterioration, families should take the following steps:
speak calmly to the person experiencing distress
reassure the person that he or she doesn't have to face the crisis alone
try to lessen the fear surrounding the experience of the illness and potential treatment
call the local mental health emergency team, crisis line, mental health centre or family physician
identify a person with whom your relative has a trusting relationship, and attempt to work through that person
call the police as a last resort in life or death situations or if none of the other options are available to you
Families should be prepared to provide the following information to the police either by telephone or upon police arrival:
What has happened
What is happening now
Identity and date of birth of the person who is experiencing distress
Is your relative being prescribed any medication?
Has he/she been taking the medication? What is it?
Has your relative been taking street drugs or alcohol?
Does your relative have access to firearms or other weapons?
Does the person have a previous history of attempted suicide or violence?
Have the police been called to the residence before?
Name of the family doctor and telephone number.
Can he or she be reached for consultation?
Does the person have a therapist? If so, can the therapist be contacted?
Is your relative involved with the local mental health centre? If so, who is the contact person?
Mobile Crisis Assessment: Car 87
For the Vancouver Police Department, standard police procedure in community mental health assessment situations is to call Car 87, a special partnership unit comprised of a police officer and a mental health clinician (usually a psychiatric nurse or mental health worker) who use non-threatening measures towards the person in distress. In Vancouver, the car only operates outside normal business hours; daytime emergencies are handled by workers at one of the mental health teams. Car 87 answers about 1,000 calls a year.
TASER Guns
The TASER gun is a device that propels tiny probes, attached to the gun by two cords. A high voltage, low wattage current runs through the cord, temporarily paralyzing the individual when the darts penetrate the skin or clothing. It is not a substitute for non-violent crisis intervention approaches, but can be a life-saving alternative to the use of "lethal force", in situations where there is an imminent threat, after other alternatives have been attempted. The use of the TASER is also limited to situations where the individual is not wearing bulky clothing (which would prevent the probes from being effective). In addition it cannot be used in situations which are beyond the range of the attachment cord (approximately 20 feet), and in extremely close-in situations, where the police officer may be in danger.
Some Rights of Individuals Admitted Involuntarily to a Psychiatric Hospital, and Rights of Families
the right to be informed of the reasons for detention and of the available review process
the right to a review panel with an advocate representing the individual
the right to counsel from a lawyer in cases where the individual was committed under the Criminal Code of Canada
the right to be fully informed of the rules and regulations and legal rights pertaining to the person's hospitalization
the right to see his or her hospital record, to attach a statement of corrections and to have specific parts of the record copied, without charge, unless harmful to third parties or self
the right to have all information relating to care while hospitalized shared only with individuals directly involved with treatment of the person, except where required under law
the right, if eligible, to vote in any municipal, provincial or federal election
the right not to be subjected to any form of cruel and unusual treatment or punishment
the right of access to an independent organization to investigate any alleged violations of these rights
for families, the right to be informed of the detention of their family member
Source: Riverview Hospital Charter of Patient Rights
Sources
Canadian Mental Health Association, BC Division. (2004). BC's Mental Health Act in plain language. Vancouver: Author. www.cmha.bc.ca/files/mha_plain.pdf
Chan, A. & Noone, J.A. (Eds.) (2000). Emergency mental health educational manual. Vancouver: Mental Health Evaluation and Community Consultation Unit. www.mheccu.ubc.ca/documents/publications/emh-manual.pdf
Province of British Columbia. (2004). Mental Health Act: [RSBC 1996] Chapter 288. Victoria: Queens Printer. www.qp.gov.bc.ca/statreg/stat/M/96288_01.htm
Province of British Columbia. (1998). Bill 22 – Mental Health Amendment Act, 1998. www.legis.gov.bc.ca/1998-99/3rd_read/gov22-3.htm
Province of British Columbia. (1998). Official report of debates of the Legislative Assembly (Hansard): Thursday, June 25, 1998. www.legis.gov.bc.ca/hansard/36th3rd/H0625PM.HTM
Riverview Hospital. (1995). Charter of patient rights. BC Mental Health Society.
Links in the Sources section are up to date as of June 2006
