How does Ontario respond to people in crisis — and how should it?

TVO.org speaks with David Gratzer of CAMH about policing, de-escalation, wellness checks, and how to change the system after decades of neglect
By Matt Gurney - Published on Jun 24, 2020
The Centre for Addiction and Mental Health, in Toronto, is Canada’s largest mental-health-focused hospital. (Fred Lum/CP)

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On June 23, Toronto’s Centre for Addiction and Mental Health, the country’s largest mental-health-focused hospital, released a statement calling for changes to how Ontario deals with mental-health crises. “Recent events have exposed the tragic outcomes that can occur when people with mental illness experience a crisis in the community and are not able to get the care that they need. Racism and anti-Black racism compound these crisis interactions,” the statement said in part. “For too long, the health care system has relied on police to respond to mental health crises in the community. Transformative change is needed to support a new way forward.”

TVO.org spoke with David Gratzer, a medical doctor and psychiatrist at CAMH, to get more insight into what needs to change.

Matt Gurney: I understand that there isn’t going to be a “typical” case where law enforcement is called out to deal with a mental-health crisis, but, in general terms, what’s a scenario that might see this happen?

David Gratzer: That can look like many different things. Mental health and mental illness are broad terms. A “mental-health crisis” is going to be equally broad. It could mean a person in a community is struggling with depression and becomes suicidal. It could mean that someone with a history of major mental illness becomes agitated in a convenience store. Those would both be a mental-health crisis. I emphasize that the vast majority of people with mental-health issues aren’t agitated, and they aren’t violent, but those are examples that we see in the real world.

Police also respond to one other kind of mental-health call. That’s a “wellness check” visit. I bring that up, without getting into the details of either incident, because of some recent stories in the news where wellness checks have had tragic outcomes. But in general terms, with a wellness check, if someone has a history of mental illness, police can be called, perhaps by family or a health-care provider who is concerned, and the police check in on the person. So police aren’t only used in “crises.”

Gurney: Again, in basic terms, what happens at a wellness check?

Gratzer: I won’t speak for how the police would describe it. But it’s intended just to be a check in to see how someone is doing. In Ontario, the police do have the ability to bring people to a hospital emergency department. So a wellness check isn’t necessarily just a visit and chat. If they feel the person isn’t doing well, if there’s a possibility of suicide or self-harm, they can bring that person to a hospital.

Gurney: “Wellness check” sounds so benign. Who could object to someone checking in on them? What relative wouldn’t want to know someone was checking in on a loved one they were worried about? But, if someone is in crisis or even is just struggling, I can imagine what it must feel like to be on a receiving end of a check.

Gratzer: The vast majority of these encounters are fine. But consider someone who might have a major mental illness and has maybe has not had good experiences with somebody in uniform — to have them show up at the doorstep, unannounced, can be perceived as very intimidating. We understand that. CAMH as an institution and me as a physician feel we can do better. We feel that passionately. We’ve had a system in place for many years, and it’s not working as well as it should. If someone is having a mental-health crisis, they should be responded to by a mental-health professional. But, right now, the people in the field are the police. That’s why they respond to the calls. But a different model might get us more satisfying outcomes and be safer.

Gurney: Obviously, this conversation is unfolding against the backdrop of a much bigger and very controversial conversation about police reform and systemic racism, but this particular slice of it is interesting to me because I come from a family full of cops. I know a ton of people in law enforcement. And you know what? They hate doing these calls. They don’t think it should be the police responding to those calls. I think they agree with a lot of their critics who say we should get police out of this. There’s two kinds of calls cops tell me they fear doing: random roadside encounters when they’ve pulled someone over and they don’t know what they’re getting into when they walk up to the driver’s window, and mental-health-crisis calls. They don’t want to be doing this. They don’t feel equipped or trained for it.

Gratzer: Mental-health-care professionals have that training — especially de-escalation. We’re really good at it. Most of our cases don’t need it. We’re usually working with people who come in with a positive desire to get better with a mood disorder or an addiction issue. But there are the scenarios where we have to de-escalate, and we know how to do that. This is what we do. I should note that police have gotten better with this. There is more training. Police are recognizing the need to do de-escalation work. There has been improvement. We recognize that. But we still think we can do better. As an organization, CAMH hasn’t recommended a specific model. We may not. We’re talking about it a lot, and there are examples around the world we can look to. But we can do better than this. But I think we will need a made-in-Canada solution that fits our specific circumstances.

Gurney: We can’t just look at the United States or the United Kingdom and conclude that what might be working there would work here.

Gratzer: Right. As tempting as it is to just announce that we have the answer, we’re going to need to work on that, to build out a new model that works here. And a big part of that model has to be a flexible response. Like I told you earlier, “mental-health crisis” is a very broad term. A 15-year-old who’s distraught over the end of a romantic relationship may need an intervention, but it won’t be the same kind of intervention as a 65-year-old with decades of substance abuse or major depression who is suicidal. We can think through all kinds of scenarios, and some small minority of them probably would need law enforcement to be involved. But we need to be smart and to use the right people in the right role. We’ve had the best of intentions, but an armed person in a uniform can be very frightening, and that can make a crisis worse.

Gurney: I am very mindful that you’ve said above that there isn’t a specific model that you or CAMH are recommending at this time. But can we talk in even general terms about what we might hope to see in a future model for Ontario?

Gratzer: Sure. Yeah. Let’s say there’s a crisis. 911 has been called. We should send someone to the door who is a trained mental-health professional, who isn’t in a uniform. They don’t have a gun. Ideally, they might already know the person and have a specific relationship with them. But someone who is, first and foremost, a health-care provider.

Gurney: You had mentioned de-escalation before, as something that you do in the hospital, and you and your colleagues are good at it. We also talk about that, often in the aftermath of a tragedy — people want to know: Did the police have de-escalation training? Did they try to de-escalate? Was there time to de-escalate before force was used? And so on. What is de-escalation?

Gratzer: It’s a way of talking to a patient. It’s intended to be disarming and calming, ideally. It’s avoiding, intentionally or otherwise, being provocative, ramping up tension.

Gurney: We have thousands and thousands of police officers in Toronto. We have thousands more of them in the surrounding regions. We could call in military troops if the police needed even more backup to deal with an emergency. We have manpower and firepower. But, if we did settle on a model for a better way of handling mental-health issues, would we have the manpower for that? Are there enough trained professionals in Toronto, and Ontario more broadly, just waiting to go but, for various reasons, we just aren’t using them?

Gratzer: Good question. It’s somewhere in the middle. What we are talking about is achievable. Some kind of new model is not an impossibility, either financially or practically. We could do this. But we couldn’t do it tomorrow. After we settle on a new model, we would have to get the right people, develop policies, and then train people in them. But we also need a reset and a rethink. We’re talking today about how to handle crises, right? And, for obvious reasons, it’s in the news. But a big part of this new model has to be better mental-health care in general, so fewer people end up getting to that crisis point in the first place. The current model produces tragic outcomes, yes, but it also doesn’t work for a lot of people who never have a tragic outcome, per se, but need help they don’t get. And this is especially true with racialized or otherwise marginalized communities.

Gurney: Right. That’s a whole other side of this. A police officer may have a bias against a person of colour, and that’s a problem, but if that person of colour could get their mental-health-care need met before it became a crisis, the encounter between the police and the individual could potentially be avoided entirely.

Gratzer: We have underfunded the mental-health-care system for decades. I know that you have written about this yourself. The system doesn’t work well for anyone. There was a paper a few years ago in the Canadian Journal of Psychiatry that found, using census data, that only half the people who needed help for major depressive disorders were getting even minimally adequate help — some level of psychotherapy or medication. So the other half aren’t. That’s the overall national number. But we know that minority groups do much worse than that average. And part of that is us as medical-care providers needing to up our game.

Years ago, I was working at a community hospital, and we introduced free evidence-based psychotherapy — free to the user, of course. And we tracked the outcomes, and we noticed that one ethnic group was not coming back. It was a noticeable difference. We followed up and asked why they were dropping out and discovered that it was a cultural issue. In their mind, getting medical care meant getting medication. They didn’t think that talk-based therapies made much sense. Our biases led us to believe people would be equally interested in this form of treatment without us having to do any explanation of the benefits of evidence-based psychotherapy.

That’s just one example. Work my colleagues are doing on these matters is hugely important. There are language issues and cultural issues. So we need to do better at that. But we also just need more funding. Canada does not fund mental-health care well, compared to international standards. We spend about eight or nine cents of every health-care dollar on mental health. In the U.K., it’s more like 13 cents.

Gurney: I want to ask you a big-picture question. And it’s kind of unfair to ask, since there isn’t going to be an easy answer. But what is the problem here? We have worked so hard over the last five or 10 years to reduce stigma, to get people talking about their own mental-health-care struggles, and to talk openly about treatment. “Mental health is health,” is something we now hear a lot. And I really do believe we’ve made some progress overall. But at the pointy end of the spear, where we have police responding to mental-health calls and some tragic outcomes, have we made any progress there at all? Why is this so hard?

Gratzer: That’s a great question. I think you nailed it. We really have made progress. We have worked hard to reduce stigma and break down barriers. Look at the pandemic. During SARS, no one talked about mental-health challenges. But, this time, the prime minister, the premier, numerous public-health officials — they are all making a point of putting mental-health treatment front and centre. And that’s great.

But this is all happening after decades of neglect. And we have structures in place that evolved during those decades that aren’t what we want them to be and aren’t what our understanding of best practices would be. There hasn’t been the kind of public-policy discussion around these issues that we’ve needed. So, yes, it’s better now. Truly. But we are far behind.

This interview has been condensed and edited for length and clarity.



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