It’s been two years since the COVID-19 pandemic forced worldwide lockdowns, and the anniversary had prompted a lot of reflection about how much life has changed.
It’s a different anniversary for me. Amid the stay-at-home orders and corona-chaos of March 2020, I was admitted to an inpatient mental health facility.
A year earlier, a severe manic episode had resulted in a diagnosis of bipolar I disorder, and while treatment had quickly alleviated my manic symptoms, I swung into a deep and intractable depression. The many projects I had taken on at the height of my mania now sat abandoned as I struggled to get out of bed. I went for days without the energy to shower or even change clothes. I hadn’t been able to work for months, and I lost my partnership with the law firm where I practiced and the executive position I also held with a startup company.
I had previously been resistant to the prospect of inpatient treatment, but even if I had the energy, I couldn’t deny that it was what I needed.
My girlfriend took me to a local mental health clinic and crisis stabilization center. They found a bed for me at an inpatient facility two hours away, and said that they’d arrange for transport.
It was the beginning of what felt more like incarceration than voluntary commitment. I had to consent to being hospitalized in a locked unit. If I decided that I wanted to be discharged, I’d have to wait up to 72 hours until a mental health professional cleared me for release or decided to have me involuntarily committed. And although I was cooperative, nonviolent, and wasn’t threatening to hurt myself, I’d have to have to be transported in the back of a law enforcement vehicle while in handcuffs attached to a chain around my waist.
It was the second time a mental health crisis resulted in me being handcuffed in the back of a police car. Within the cramped, stuffy, steel mesh cage, I sat at an angle so that I would have room for my knees and legs. I shifted my wrists and arms to allow the handcuffs and chain to settle before finding the least uncomfortable position to rest my hands. Then I closed my eyes and tried to focus on my breathing as I skirted the edge of a panic attack for the next two hours.
Source: Kindel Media/Pexels
A Lack of Resources and Standards
Legal and regulatory standards required by the Centers for Medicare & Medicaid Services (CMS) guidelines prohibit the use of law enforcement restraints for behavioral health patients in hospital settings unless the patient is under law enforcement custody. For inpatient psychiatric units, law enforcement restraints are never allowed to be used. However, no such standards exist for transport to or between hospital settings.
Unfortunately, the lack of medical transport resources and options has meant that it is common practice for law enforcement officers from police and sheriffs’ departments to transport mental health patients between acute and long-term mental health facilities. When department policies combine with the general misconception that mental health patients are automatically a danger to themselves and others, patients in crisis get treated like criminals under arrest.
The use of law enforcement restraints to transport all mental health patients unduly traumatizes those who are already in crisis. It can also convert a compliant patient into a combative one, particularly among those on the autism spectrum.
Furthermore, many individuals with mental health problems also have other serious medical issues. Having law enforcement professionals without adequate medical training responsible for restrained patients who may medically decompensate during transport can expose those professionals and their departments to significant liability risk.
A Collaborative EMS Approach
What is needed is a shift to a model in which mental health patients being transferred between facilities are transported by medical professionals trained to manage both mental health and medical conditions. Restraint guidelines should be in accordance with CMS guidelines for hospital restraints, and no patient who is not in legal custody should be transported in law enforcement restraints.
For patients with a high risk for agitation and/or violence, medically indicated interventions can include medication and/or medical restraints. Law enforcement officers may be requested to provide support and ensure everyone’s safety. This approach provides a collaborative solution that combines adequate medical support with safeguards to protect the safety of all involved.
It’s an idea whose time has come. As Angela Strain, MD, chief of the Division of Emergency Psychiatry at UNC School of Medicine, has stated, “We don’t want to be criminalizing mental illness. Nobody likes the idea of putting someone who is in a psychiatrically fragile state into shackles in a police vehicle.”