Running Head: MENTAL HEALTH DIVERSION FROM EDs

MENTAL HEALTH DIVERSION FROM HOSPITAL EMERGENCY
DEPARTMENTS: ASSESSING A JOINT EFFORT OF TWO
MENTAL HEALTH METHODS AND POLICE PARTNERSHIPS

by
Peter Vermeulen

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF PSYCHIATRIC NURSING

The Faculty of Graduate Studies
(Health Studies)

BRANDON UNIVERSITY
December 2019
© Peter Vermeulen, 2019

ii
Peter Vermeulen, Master of Psychiatric Nursing, Brandon University
Abstract of Master’s Thesis, Submitted January 29, 2019
Mental Health Diversion from Hospital Emergency Departments: Examining the
Effectiveness of a Joint Effort of Two Mental Health and Police Partnerships.
Purpose
The purpose of this research was to examine both individual and joint efforts in mental
health collaboration and how individual and group initiatives can lead to decreased
emergency department (ED) presentations and improved client care. Local and
international literature is presented as a way to inform, advise, or hypothesize about
known gaps in literature.
Method
Secondary data from the 2016 calendar year was accessed through Alberta Health
Services (AHS). All Mental Health Act apprehensions that occurred in the City of
Edmonton during the 2016 calendar year comprise the secondary data. Data surrounding
Mental Health calls for service for both Urgent Services, the Police and Crisis Team, and
the Edmonton Police Service was captured and analyzed with a chi-square analysis, with
a focus on the call disposition.
Results
Research findings indicated the presence of a mental health clinician through either a
Knoxville or Separate Response Model influenced person/people with mental illness
(PMI) being admitted to hospital post mental health apprehension. PMI brought to an
emergency department via a mental health act apprehension without a mental health
clinician were more likely to be discharged. An informal partnership (Separate Response
Model) was more successful than a formal partnership (Knoxville Model) in diverting
PMI away from hospital. Regardless of substance use, there was no difference in
disposition between substance and non-substance related mental health apprehensions.
Findings from this research indicate mental health and police collaboration improves
client care through timely access to appropriate care.
Keywords: schizophrenia, first-responder, psychiatric nurse, mental health,
mental illness, addictions, bizarre behavior, suicidal, police, collaboration, Crisis
Intervention Team, Knoxville Model, Birmingham Model, crisis negotiation,
Canada.

iii
Lay Summary
Secondary data available from Alberta Health Services (AHS) was analyzed to determine
the difference in outcome between the presence of, and the absence of mental health
involvement at the time of a mental health crisis. The involvement of a mental health
clinician at the time of crisis had an effect on diverting the person away from the
emergency department, to safe and effective community resources. Client outcomes
between two different mental health and police collaborative models were examined. An
informal mental health and police partnership was more successful in diverting clients
away from the emergency department than was a formal mental health and police
partnership. Data was reviewed and analyzed to determine if there was an outcome
difference between substance related and non-substance related Mental Health Act
apprehensions. The presence of substance use at the time of a Mental Health Act
apprehension did not affect whether or not the client was admitted to the hospital.

iv
Preface
This document is based on research conducted by Peter Vermeulen who was responsible for
reviewing the literature, designing the project, ensuring ethics approval, obtaining secondary data
from Alberta Health Services, and analysis and interpretation of findings.
The thesis committee was comprised of Dr. Penny Tryphonopoulos, Dr. Nora Ahmad, and Dr.
Brian Larson, without whom this project would not have been possible. Although not a thesis
committee member, Cheryl Chorney provided exceptional guidance and support.
Brandon University Research Ethics Committee: “Mental Health Diversion from Hospital
Emergency Departments: Examining a Joint Effort of two Mental Health and Police Partnerships”
# 22427.
University of Alberta Research Ethics Committee on behalf of Alberta Health Services:
Pro00089675.

v
Table of Contents
Abstract ………………………………………………………………………ii
Lay Summary………………………………………………………………...iii
Preface………………………………………………………………………..iv
Table of Contents…………………………………………………………….v
List of Tables…………………………………………………………………vii
List of Figures………………………………………………………………..viii
List of Abbreviations………………………………………………………...ix
Dedication ………………………………………………………..…………..x
Chapter 1: Introduction …………………………………………………….1
1.1 Research Problem……………………………….…………….......1
1.2 Background………………………………………………………..2
1.3 Significance………………………………………………………..3
1.4 Current Models of AHS mental health and police collaboration….6
Chapter 2: Literature Review ………………………………………………8
2.1 Police as the Initial Responder……………... …………………. …8
2.2 Police Encounters with PMI…………………...…………………..13
2.3 Mental Health Crisis Response Models ….……………….............16
2.4 Police Perception of Mental Health……………………………….21
2.5 Therapeutic Communication………………………………………23
2.6 Post-Mental Health Apprehension Disposition……………………25
2.7 Overview of PACT and Urgent Services Consultation……………27
Chapter 3: Methods……………..……………………………………………28
3.1 Ethics……………..….………………………………………….…29
3.2 Pathway to Patient Care……………………………………………30
3.3 Research Design .…………………………………………….....…32
Research Question 1……………………………………….......32
Research Question 2…………………………………………...32
Research Question 3…………………………………...………33

vi
Chapter 4: Data Analysis and Findings ……………………………………33
4.1 Research Question 1.………………………………………….......34
4.2 Research Question 2. ……………………………………………..36
4.3 Research Question 3………………………………………………37
Chapter 5: Discussion …………………………………………………….....40
5.1 Inclusive Collaboration…………………………………………....41
5.2 Mental Health Training for Police…………………………………44
5.3 Coordinated Response……………………………………………..46
5.4 Implications and Future Research Opportunities………………….49
5.5 Limitations and Strengths…………………………………………52
5.6 Knowledge Dissemination Strategy……………………………….53
Chapter 6: Conclusion ………………………………………………………54
References…………………………………………………………………….57
Appendices …………………………………………………………………...71
Appendix A: Glossary of Terms ……………………………………...71
Appendix B: Statement of Peace Officer on Apprehension…………..72
Appendix C: Figure 1.1……………………………………………….73
Appendix D: Secondary Data Gathered………………………………74
Appendix E: Ethics Certificates ……………………………………...76

vii

List of Tables
Table 1

Critical values for 2 Distribution…………………………34

Table 2

Data for Research Question 1……………………………...34

Table 3

Data for Research Question 2……………………………...36

Table 4

Data for Research Question 3……………………………...38

viii

List of Figures
Figure 1.1

Patient Pathway with EPS………………………………….73

ix

Abbreviations Used
AHS:

Alberta Health Services

ALS:

Active Listening Skills

AMH:

Addictions and Mental Health

CIT:

Crisis Intervention Team

CRHT:

Crisis Resolution and Home Treatment

ED:

Emergency Department

EPS:

Edmonton Police Service

ICMS:

Integrated Mobile Crisis Service

MCRRT:

Mobile Crisis Rapid Response Team

MHAA:

Mental Health Act Apprehension (e.g. Form 10)

MHIST:

Mental Health Investigative Support Team

PACER:

Police Ambulance Crisis Emergency Response

PACT:

Police and Crisis Team

PMI:

People/Person with Mental Illness

RAM:

Ride-Along Model

RCMP:

Royal Canadian Mounted Police

SMART:

System-wide Mental Assessment Response Team

TASER:

Thomas A. Swift’s Electric Rifle (e.g. less lethal electronic weapon)

US:

Urgent Services

x

Dedication
My father survived World War II and came to Canada in 1967 at the age of 30,
being able to speak limited English. Through determination, German efficiency, and
unparalleled stubbornness, he taught himself university-level math from an English
textbook. In doing so, he was able to successfully challenge the first-year of the
Engineering program at the University of Alberta and made a good life, providing for our
family of five. Dad passed away unexpectedly in 2019, prior to the completion of this
thesis. He was a great man and I miss him every single day.
My son Will was born in 2017 during the writing of this thesis. His little body
was broken and he left us the same day he arrived. Will never got to meet his older sister
Nora, who fills my days with unequivocal joy and happiness. Will’s little sister Estelle
was born two years after him. Estelle’s curiosity of the world around her continues to
amaze me each and every day. There is never enough time to spend with your kids. I
look forward to watching them grow.
In 2012, an amazingly brilliant and beautiful nurse took a chance and decided to
go out for “donuts and beer” with me. Nearly eight years later, I wake up every morning
as the happiest man alive. Michaela has continuously pushed, supported, and encouraged
me at every step of this graduate program whilst completing and defending her own
thesis. Without her unconditional love, this research could have not been completed.
She still gives me butterflies.

Running Head: MENTAL HEALTH DIVERSION FROM EDs
Chapter 1 – Introduction
1.1

Research Problem
Mental health training for police is often a recurrent issue in the Canadian media.

As first-responders to calls for service involving persons with mental illness (PMI),
police act as ad hoc gatekeepers for mental health services (Canada, Angell, & Watson,
2012). Mental illness can present to police in the form of unfounded complaints, bizarre
or suicidal behaviors, or frank psychosis. Police calls for service involving PMI are twice
as long compared to non-PMI related calls (Charette, Crocker, & Billette, 2011). The
topic of mental health training can arise following a fatal interaction between police and
PMI. Prior to 1988, there was no formal, structured collaboration between police and
mental health providers (Dupont & Cochran, 2000). Following a fatal encounter between
police and a person with schizophrenia, the Crisis Intervention Team (CIT) model of
mental health and police collaboration was created (Borum et. al., 1998). Despite being
the first developed model of mental health and police collaboration, the CIT model does
not include the presence of a mental health clinician at the time of crisis (Borum et. al.,
1998; Dupont & Cochran, 2000). Though common in the United States, CIT is not
prevalent in the Canadian setting (Coleman & Cotton, 2010). Publicly funded Canadian
and privately funded American healthcare systems are fundamentally different, enabling
greater access to mental health and police collaboration in a Canadian setting.
This research examined the effectiveness of police accessing a mental health
crisis service through collaboration between a Knoxville Model collaborative team (see
Appendix A) and a Separate Response Model (see Appendix A) of mental health
intervention.

2
The effectiveness of a Knoxville Model and a Separate Response Model in
diverting PMI away from the emergency department (ED) will be compared to the
effectiveness of a police-only approach. The effectiveness of diverting PMI from the ED
by a Knoxville Model will be compared to the effectiveness of a Separate Response
Model. Lastly, inpatient admission rates following a Mental Health Act apprehension
(MHAA) for individuals apprehended due to substance-related concerns will be
compared to a non-substance related apprehension.
It is hypothesized that the presence of a mental health clinician via either the
Knoxville Model or Separate Response Model, at the time of mental health crisis, will
result in PMI being diverted from the ED to safe and effective community services. It is
hypothesized that a formal mental health and police partnership (e.g. Knoxville Model)
will have a greater ability to divert PMI away from the ED compared to an informal
mental health and police partnership (e.g. Separate Response Model). Lastly, it is
hypothesized that individuals apprehended on a substance-related MHAA will be
discharged from the ED more often, compared to individuals apprehended on a nonsubstance-related MHAA.
1.2

Background
Deinstitutionalization has resulted in more PMI being discharged into

communities that lack services to safely and effectively stabilize this population
(Bachrach, 1983). As a result, police services are left as the de facto mental health
providers (Patch & Arrigio, 1999). Police members facing calls involving PMI are left to
make critical decisions regarding the need for psychiatric intervention; thus, acting as a
gateway for the mental health system (Canada, Angell, & Watson, 2012).

3
Police are duty-bound to ensure safety for a population. When police are unable
to ensure the safety of PMI, police act to provide PMI with access to a healthcare
professional. Safety will be paramount over all other concerns. Police serve as a contact
point for accessing addictions and mental health services. Patrol members are the most
likely to be the initial responders to encounter persons in mental health crises (Lamb,
Weinberger, & DeCuir, 2002). Regardless of the reason behind a call for service, police
are tasked with ensuring a safe and effective outcome for community members. Whether
or not an individual is suffering from an acute mental illness or a substance-induced
disorder at the time of police involvement, is immaterial. Police are left to mitigate the
risk of the presenting signs and symptoms, from either a psychiatric or a substanceinduced etiology, if not both. The Mental Health Act of Alberta specifies PMI who are
apprehended by police must be conveyed to a designated facility (Mental Health Act,
R.S.A., 2010). Designated facilities are healthcare settings, typically a traditional
hospital, largely located in urban areas. A designated facility has the resource capacity to
care for PMI who are detained via the Mental Health Act. In the event PMI are
apprehended by police in a rural setting, available designated facilities would likely be
limited in comparison to those available in a large city.
1.3

Significance
In Edmonton, prompt access to mental health crisis services has negated the need

for police patrol members to complete a MHAA in nearly 100% of cases (personal
communication Pamela Coulson, June 2017). In December 2016 when prompt access to
community based mental health crisis services did not occur, nearly 70% of PMI

4
apprehended by Patrol were discharged from the emergency department (ED) (personal
communication Pamela Coulson, June 2017).
It is anticipated the results will reflect the existing mental health knowledge base
of police members. It is also anticipated the results will reflect on common occurrences
precipitating police calls for service (e.g. substance use resulting in police intervention).
Research results will assist in clarifying areas of success within police training and may
potentially address areas for improvement. Research results will equally identify areas
where involving a mental health professional is ineffective.
Successful diversion of PMI away from the ED to appropriate and effective
mental health services would be of benefit to multiple stakeholders. Fewer MHAA
presentations to the ED may help to increase police presence on the streets, which, in
turn, would allow police to focus on proactive crime prevention and decrease responseto-call times. Decreased MHAA presentations to the ED would relieve ED bed
pressures. Fewer MHAA presentations to the ED would place less pressure on the acute
environment of the ED. The purpose of this research is to examine the outcomes of two
mental health and police collaborative models in diverting PMI away from the ED to
appropriate and effective community resources and services.
Outcomes following a MHAA with and without prior consultation to a mental
health crisis service will be examined. Recognition of mental health issues by police and
the effectiveness of existing community mental health supports will be examined. Areas
for improvement and expansion may be identified with the end goal of improving client
care. Outcomes from research may directly benefit an area of law enforcement and
mental health collaboration that remains in its infancy. Psychiatric Nurses stand to play a

5
role in diverting PMI from a MHAA through effective recognition, assessment and
stabilization to appropriate services in the community.
In a Canadian study based in British Columbia, most of the contact between
police and PMI was informal in nature (75%) and street stop-and-checks (68%)
(Livingston, Desmarais, Verdun-Jones, Parent, Michalak, & Brink, 2014). Police are
regarded as the initial gatekeeper for mental health services as they are first-responders to
calls for service involving PMI (Canada, Angell, & Watson, 2012). Charette et. al.
(2011) found Canadian police calls for service involving PMI were twice as lengthy (89.1
minutes) as non-PMI (40.4 minutes) calls for service.
In review of existing literature, the dominant model of mental health and police
partnership is the Crisis Intervention Team (CIT) model. The CIT model, originating
from Memphis Tennessee, involved formal mental health training for police members
(Borum et. al., 1998). Although a dominant model in the United States, this model is less
prevalent in Canada (Coleman & Cotton, 2010) likely due to the presence of a publicly
funded healthcare system, enabling greater police and mental health stakeholder
partnership. The CIT model is not one of the mental health and police partnerships
examined in this research.
The Knoxville Model of collaboration involved a partnership between police and
a community agency (Borum et. al., 1998; Deane et. al., 1999) and has been identified as
the preferred time and resource intensive choice (Brown Cross et. al., 2014; Shapiro,
Cusi, Kirst, O’Campo, Nakhost, & Stergiopoulos, 2015). The original concept of police
and community agency partnerships had evolved to include the Ride-Along Model
(RAM) (Boscarato et. al., 2014), the Police Ambulance Crisis Emergency Response

6
(PACER) model (Huppert & Griffiths, 2015), the Integrated Mobile Crisis Service
(IMCS) out of Halifax (Kisely et. al., 2010), and the System-wide Mental Assessment
Response Team (SMART) out of Los Angeles (Lamb et. al., 1995). Health service and
police partnership is more prevalent in Canada, as Canada has a publicly funded health
care system and stricter gun control laws, allowing for greater mental health and police
collaborative efforts (Coleman & Cotton, 2010). Specific to this research, the Knoxville
Model examined is the formal partnership between Alberta Health Services (Police and
Crisis Team – PACT) and the Edmonton Police Service.
The Separate Response Model comprised informal collaboration between mental
health and policing, where both stakeholders are involved on the scene but arrive
independently of one another (Boscarato et. al., 2014). Specific to this research, the
Separate Response Model examined is the informal collaborative effort between Alberta
Health Services’ Urgent Services team and the Edmonton Police Service.
1.4

Current models of AHS mental health and police collaboration
Diversion away from hospital EDs to community resources by members of the

Edmonton Police Service (EPS), the Police and Crisis Team (PACT) and Urgent Services
(US) will be examined. Inpatient admission rates from calls for service involving
consultation to Urgent Services, a Separate Response Model of collaboration, and the
Police and Crisis Team (PACT), a Knoxville Model of collaboration will be compared
and contrasted. The prevalence of substance related MHAA will be examined. Finally,
inpatient admission rates following MHAA by EPS will be examined.
Urgent Services is a publicly funded 24/7 service run by Alberta Health Services
(AHS) wherein any community member, including police, can access or consult

7
addiction and mental health services on an urgent basis. US is comprised of a
multidisciplinary team including: Registered Psychiatric Nurses, Registered Nurses,
Occupational Therapists, Registered Psychologists, and Masters-prepared Social
Workers. US maintain a call centre where calls are assessed and triaged. If the call
cannot be resolved with safe and effective stabilization, US completes a mobile mental
health assessment. The resulting mobile mental health assessment may result in a
connection to community-based services. Alternatively, US may liaise with EPS in the
event a MHAA is deemed appropriate. Ultimately, the decision to enact a MHAA (see
Appendix B – Form 10) would be determined by EPS; however, US would advocate for
the client and highlight the level of risk present.
PACT is comprised of an US staff member employed by AHS paired with a
designated EPS member. PACT operates in both a first responder and consultative
capacity with both EPS members and US staff. At times, police may be left with no other
option than to complete a MHAA to ensure safety for the individual and the community.
The Urgent and Intensive Services portfolio with AHS includes both Urgent
Services and PACT. Between the Urgent and Intensive Services portfolio and EPS,
MHAAs (see Form 10 in Appendix A) have been tracked between January 1, 2016 and
December 31, 2016. Data specific to EPS involvement was gathered from all four
hospital ED sites in Edmonton where Form 10s can be taken. The suburban RCMP
detachments also must bring their MHAAs to one of four Edmonton hospitals; however,
those outcomes are not reflected in the data.
The governing body of the EPS, the Edmonton Police Commission, had requested
service-wide outcomes surrounding MHAA (personal communication, Cst. R. Martynuik,

8
2013). The data is accurate and accessible through Pamela Coulson, the Edmonton Zone
Director of Urgent and Intensive Services of AHS.
Evaluation research serves to determine whether or not a program is meeting its
goals (Polit & Beck, 2012). No evaluative research of inpatient admission rates
following MHAA could be found in the literature. Evaluation of the effectiveness of two
separate mental health and police collaborative models will help to justify the programs’
successes and will serve to further promote expansion of existing services. Impact
analysis along with secondary analysis will be used in the research.
Although there is evidence of effective individual models of mental health and
police collaboration, there is a gap in the literature regarding collaboration between two
mental health and police collaborative models within one geographical setting.
Additionally, there is a gap in the literature regarding inpatient admission rates in general,
but more specifically no known data on inpatient admission rates of a joint-partnership of
two collaborative partnerships working together. It is anticipated results of this research
will offer new findings through a retrospective analysis of accessible data. It is feasible
and will add to the existing body of literature. The results of this research will fill an
identified gap in the knowledge base (Cotton & Coleman, 2010; Tyuse, 2012; Cotton et.
al., 2007; Compton et. al., 2008).
Chapter 2 - Literature Review
2.1

Police as the initial responder
Police are often first responders to situations involving mental illnesses (Augustin

& Fagan, 2011; Boyd, Boyd, & Kerr, 2015) and are recognized as first-responders to a
plethora of non-criminal societal issues (Bittner, 1967) with often limited and inefficient

9
police resources (Boyd et. al., 2015). As first responders to calls involving mental health,
police are often referred to as the initial gatekeeper for mental health services and the
criminal justice system (Canada, Angell, & Watson, 2012; Grudzinskas, Clayfield, RoyBujnowski, Fisher, & Richardson, 2005; Hartford, Carey, & Mendonca, 2006; Lamb,
Weinberger, & Gross, 2004; Patch & Arrigo, 1999).
Police are often regarded as being society’s general-purpose emergency service,
given that they are called upon when all other options have been exhausted (Olivia &
Morgan, 2010). Police were identified as having substandard training and yet, they were
put in the position of gatekeeper to mental health services (Laing, Halsey, Donohue,
Newman, & Cashin, 2009). Nuisance behaviors are acts that annoy or bother members of
the general public (Baillergeau, 2014) but may be non-criminal in nature. Adding to this,
nuisance behaviors placed pressure for resolution on police, largely due to public
perception (Schulenberg, 2016). Police and Corrections were agencies never intended to
provide mental health services, yet are expected to have regular dealings with persons
with mental illness (Martinez, 2010).
The deinstitutionalization of PMI (e.g. the closing of inpatient psychiatric
institutions and reintegration of PMI into community settings) occurred in response to
several factors: the cost of inpatient treatment, emergence of new psychotropic treatment,
increased public awareness to substandard conditions, and human rights violations
(Novella, 2008). Initial involvement with police and PMI is viewed as a necessity in
response to a failed system (Cotton & Coleman, 2010). PMI are subjected to criminal
prosecution due to a number of factors including the aftereffects of deinstitutionalization;
police management of mental health crises; and inadequate access to treatment (Hartford

10
et. al., 2006). Deinstitutionalization occurred with minimal foresight to consequences
(Cotton & Coleman, 2010; Lurigio, 2000) and resulted in increased homelessness and
mental illnesses in prison due to inadequate community supports (Chappell, 2010).
Furthermore, deinstitutionalization resulted in increased PMI coming to police attention
(Patch & Arrigo, 1999) and zero-tolerance policies were noted to further criminalize PMI
(Schulenberg, 2016). Changes in involuntary commitments further limited access to
services (Lurigio, 2000). The use of the medical model in treating PMI is ineffective, as
the medical model does not address socio-economic issues (Grudzinskas et. al., 2005);
however, while in custody, PMI often go unnoticed unless acute symptomatology is
present (Lurigio, 2000). Existing outpatient services were largely compartmentalized
with more exclusionary than inclusionary criteria (Lurigio, 2000) thereby limiting
restraining accessibility of these services.
Police criminalization of PMI has been viewed as a means of connecting PMI to
mental health services, yet mental health services are rare and long term follow up does
not exist in the criminal justice system (Lurigio & Watson, 2010). Mental health calls
were common and significant operational problems for all police (Borum, Deane,
Steadman, & Morrissey, 1998) and are frequent and time-consuming (Boyd et. al., 2015).
A review of the literature noted police often handle mental health calls informally, since a
mental health apprehension is time intensive (Lord & Bjerregaard, 2014). Police are
pressured to take calls for service, yet the time-intensive nature of a mental health
apprehension was cited as a factor in PMI being arrested as opposed to conveyed to
hospital (Lurigio & Watson, 2010). Calls to the police regarding severe mental illness
have increased, resulting in a large impact on the individual, police and the public

11
(Hensen et. al., 2016). Increased demand of PMI requiring police intervention may be a
sign of population growth as much as it could be from an increase in illness recognition
(Durbin, Lin, & Zaslavska, 2010).
Police response to PMI has become more formalized (Hartford et. al., 2006). For
example, Chicago police members are verboten by law from denying people access to
mental health services (Martinez, 2010). A common and recurrent theme amongst police
services is a deficit in members’ mental health knowledge. (Clayfield, Fletcher, &
Grudzinkas, 2011). Police are important stakeholders as effective symptom recognition
is key to formulating a disposition (Hensen et. al., 2016). Police have an obligation to
recognize and act on behaviours that stem from impaired judgment caused by a mental
disorder. Impaired judgment may result in an individual causing harm to themselves or
others, even in the absence of direct suicidal or homicidal ideation (Hoffman, Hirdes,
Brown, Dubin, & Barbaree, 2016). Police were identified as having roles other than
crime-fighter; evolving roles required increased means of meeting expectations (Charette,
Crocker, & Billette, 2014). Police are expected to quell violence, yet compassionate and
courteous behavior is equally expected (Chopko, 2011). A split between public
expectations of police actions versus what police are trained to do was identified (Demir,
Broussard, Goulding, & Compton, 2009). The majority of police encounters with PMI
did not result in emergency apprehension (Bittner, 1967); however, the demographic of
PMI involved with the legal system are often frequent users of mental health services
(Grudzinskas et. al., 2005). Police are identified as empathizers and validators of the
concerns of PMI (Bittner, 1967) however mental health is a contributive factor, not a
causative factor for a mental health crisis (Bonfire, Ritter, & Munetz, 2014). Given the

12
absence of standardized procedures for dealing with PMI, critical thinking is crucial
regardless of the circumstances for policing (Bittner, 1967).
A need for innovation is evident as police involvement with PMI had been
inefficient, resulting in long wait times and increased emergency department burden
(Huppert & Griffiths, 2015) creating a ‘bottleneck’ of PMI in the emergency department
(McKenna, Furness, Oakes, & Brown, 2015). Police involvement begins with the police
dispatcher who acts as the initial gatekeeper, far before traditional police involvement
(Canada et. al., 2012). Police dispatchers may lack awareness and training of mental
illness symptomatology; thus, police members trained in mental health are often not
consistently dispatched to mental health calls appropriately (Canada et. al, 2010). Mental
health knowledge and skill required for police dispatchers is markedly different from
other areas in policing (Coleman & Cotton, 2014). Literature surrounding mental health
training largely focuses on the front-line police member, neglecting the role of the
dispatcher (Ritter, Teller, Marcussen, Munetz, & Teasdale, 2011). Estimating risk, as
opposed to determining exact risk, has been identified as beyond the scope of policing
since police are not trained as mental health experts (Bittner, 1967). Police are left to
differentiate between para-suicidal gestures and potentially lethal suicide attempts
(Bittner, 1967). Despite the frequency of involvement with PMI, police may be
interpreted as being more accepting of PMI compared to the rest of society (Cotton,
2004).
What police are trained to do may be harmful toward PMI, their families, and
even police members (Demir et. al., 2009). For example, although fatalities with Tasers
and mental illness are rare (Parent, 2011), such fatalities are highly publicized (Chappell,

13
2010). Parent (2011) noted from 1999-2009, police in British Columbia fatally shot 30
individuals, of which eight had a history of mental illness. Risk factors with Taser use
are evident, however empirical research is lacking and currently does not indicate Tasers
to cause death; Tasers were implemented to reduce injuries to persons with mental illness
and police (O’Brien & Thom, 2014). A police response to a fatal threat may result in the
loss of life, in order to save a life (Demir et. al., 2009) yet police use of force is relatively
rare in overall police interactions (Morabito et. al., 2012).
2.2

Police Encounters with PMI
The principle of support versus punishment is imperative in ensuring effective

care delivery to PMI (Grudzinskas et. al, 2005). PMI are more likely to be arrested for
minor, non-violent offenses (Charette et. al, 2011; Grudzinskas et. al, 2005) such as
public intoxication and nuisance type behaviors. The use of criminal arrests and charges
with PMI may be attributed to a lack of diversion options, lack of treatment, or lack of
housing (Hartford, Heslop, Stitt, & Hoch, 2005). Inadequate community services and a
rigid change in criteria for civil commitment often result in prison being the only viable
treatment option for PMI (Lamb et. al, 2004). A lack of accessible mental health services
results in arrests and transport of PMI to jail – an act referred to as ‘mercy bookings’
(Lamb et. al., 2002). The American constitution guarantees healthcare services to people
in the criminal justice system, yet services offered are limited and understaffed (Martinez,
2010) whereas the Canadian constitution does not cite healthcare as a constitutional right.
In order for Provinces to receive federal transfer payments designated for healthcare, the
principles of the Canada Health Act must be followed (Canada Health Act, S.C., 1984).

14
Provincial adherence to the Canada Health Act ensures access to free, appropriate, high
quality healthcare for Canadian residents.
Access to healthcare may influence the manner in which PMI receive care. A
‘hydraulic model’ of social control resulted in lower rates of incarceration with higher
rates of PMI inpatient hospitalization; conversely low rates of PMI inpatient
hospitalization resulted in higher rates of incarceration (Grudzinskas et. al., 2005).
Mental health and legal systems are described as having ‘porous boundaries’ (Lurigio &
Watson, 2010). In other words, both are interrelated and what happens with one will
affect the other. The availability of an effective healthcare system may mitigate PMI
away from the legal system and toward patient-centered healthcare.
Police typically identify PMI under three general means: apprehending PMI on an
emergency basis for a psychiatric assessment; apprehending PMI via court order; and
encountering PMI via traditional police calls (Bittner, 1967) and contact between police
and PMI was frequently initiated by calls from the public (Lamb et. al, 2002). In a
Canadian study based in British Columbia, the majority of contact between police and
PMI was through casual, informal encounters (75%) and street stop-and-checks (68%)
(Livingston et. al., 2014).
The manner in which police perceive signs of mental illness influences how they
will respond (Hoffman et. al, 2016). PMI in low-income neighborhoods may be
misinterpreted as having addictions issues or developmental delays, when in fact a mental
illness may be present (Krishan et. al., 2014). PMI come to the attention of police as a
result of ‘overt psychiatric behavior and the associated nuisance’ (Hensen et. al, 2016,
p.2) due to an exacerbation of illness. The most common PMI presentations to police

15
have been disorganized and bizarre behavior (Lamb, Shaner, Elliott, DeCuir, & Foltz,
1995; Sheridan & Teplin, 1981) as the result of disorganized thinking, hallucinations, and
delusional ideations (Lamb et. al., 1995).
Mental health is defined as a contributive factor, not a causative factor for a
mental health crisis (Bonfire et. al, 2014). High-risk factors for mental health crises
include psychosocial and socioeconomic changes in the lives of PMI (Hensen et. al,
2016). PMI often come to the attention of police during exacerbations of emotional
disturbance (Olivia & Morgan, 2010) and must get ‘sick enough’ before an apprehension
can occur (Bradbury, Ireland, & Stasa, 2014). Middle-aged males with histories of Axis I
disorders (e.g. schizophrenia, bipolar disorder, and depression), previous criminal
involvement and previously victimized in a crime were found to be the highest risk for
potential police provoked shootings as a means of suicide (McLeod, Thomas, & Kesic,
2014).
The use of TASER devices is becoming more prevalent in high-risk calls
involving PMI. Risk factors with TASER use are evident, however, empirical research is
lacking and currently does not indicate TASER use to cause death (O’Brien & Thom,
2014). Over a ten-year period from 1999-2009 in British Columbia, police had fatally
shot 30 people; mental illness and suicidal behavior accounted for 8 of the 30 (Parent,
2011). With the eight fatalities, the TASER was deployed but unsuccessful in 3 of the 8
fatal shootings (Parent, 2011).
In a Canadian study comparing the duration of calls for service, Charette et. al.,
(2011) found calls for service involving PMI were twice as lengthy (89.1 minutes) as
non-PMI (40.4 minutes) calls for service. Furthermore, the length of time for mental

16
health apprehensions and arrests were more than double compared to an informal
disposition (Charette et. al., 2011). Schulenberg (2016) noted that encounters involving
PMI were on average 20 minutes longer than typical police calls. Referral of PMI to
mental health services was equally as time-consuming as an informal disposition
(Charette et. al., 2011). PMI who present to emergency departments with police via
police referral include the following common characteristics: male; a recent history of
violence defined as “…actual or threatened physical aggression toward another person or
toward property” (Redondo & Currier, 2003, p. 805); violence in the emergency
department; and, a lifetime history of violence and presence of acute psychosocial
stressors (Redondo & Currier, 2003). Violence to self/others, alcohol use, physical health
concerns and suspicions of medication non-compliance increased the likelihood of
transport to hospital (Ritter et. al., 2011). In a study conducted by Redondo and Currier
(2003), violence was cited as largely attributable to Axis II (e.g. emotional dysregulated
behaviors) versus Axis I pathology. Once in the emergency department, PMI who
experienced a crisis catalyst were likely to settle following food, sleep, and empathetic
human interaction (Pakes, Shalev-Greene, & Marsh, 2014).
2.3

Mental Health Crisis Response Models
Police interactions can significantly influence the lives of PMI (Livingston et. al.,

2014). The presence of mental health professionals in high-risk incidents positively
correlates to peaceful outcomes whereas a police-only approach positively correlates to
increased tension and often, undesirable outcomes (Augustin & Fagan, 2011). A
correlation between PMI was noted in high-risk incidents requiring crisis negotiation, yet
causation of mental illness and crisis situations is not definite (Grubb, 2010). Mental

17
health professionals are identified as vital stakeholders in contemporary policing
operations, from the front-line to the most acute crisis negotiations (Coleman & Cotton,
2010). The role of mental health professionals has existed in crisis negotiations, yet the
roles of mental health professionals continue to expand (Grubb, 2010). Reactive police
intervention and proactive implementation of mental health supports contribute to
positive outcomes for PMI (Bonkiewicz, Green, Moyer, & Wright, 2014). Though basic
training in mental health exists for police services, these training programs are largely
inconsistent (Augustin & Fagan, 2011). Conventional literature regarding police and
mental health collaboration advocates for an enhanced police role during interactions
with PMI (Bradbury et. al., 2014). While psychiatric nurses have the capacity to
intervene therapeutically upon their assessment of PMI, police were limited to symptom
recognition of illness (Ellis, 2014).
A pragmatic problem-solving approach brought to police work led to the success
of crisis intervention teams (CIT) (Augustin & Fagan, 2011), yet the need for increased
coordination and collaboration between mental health and police stakeholders is evident
(Boscarato et. al., 2014). Consensus regarding the level of mental health training
required for police officers remains a contentious issue (Clayfield, et. al., 2011). A lack
of police training in mental health may result in the criminalization of PMI (Lamb et. al.,
2002). Leadership at the administration level is crucial for improved knowledge, tactics,
and resources at the front-line level (Coleman & Cotton, 2010). Content specific to CIT
focused on goals of decreasing arrests of PMI and increasing access to mental health
services with the benefits of CIT training resulting in increased knowledge and skill filter
throughout the police department (Bonfire et. al., 2014; Canada, et. al., 2010; Canada et.

18
al., 2012). Additional goals of CIT include meeting the needs of PMI, keeping PMI out
of jail, minimizing police times dealing with PMI (Borum et. al., 1998) and reducing
injuries between PMI and police (Brown Cross et. al., 2014). Psychiatric nurses are
frequently identified as key stakeholders in ongoing CIT development through
partnership with police services (Ellis, 2014).
The CIT model, originating from Memphis Tennessee, involved mental health
training for police members (Borum et. al., 1998; Boscarato et. al., 2014; Deane,
Steadman, Borum, Veysey, & Morrissey, 1999) and ensured appropriate mental health
apprehensions of PMI (Broussard, McGriff, Demir Neubert, D’Orio, & Compton, 2010).
Benefits of CIT included the knowledge and ability to recognize illness (McGriff,
Broussard, Demir Neubert, Thompson, & Compton, 2010). Application of CIT
knowledge was useful in differentiating drug and alcohol behaviors from symptoms of
mental illness (Canada et. al., 2010) and resulted in better assessment, response tactics,
and disposition outcomes for PMI (Canada et. al., 2012). Symptoms resulting from
alcohol or substance abuse may be misinterpreted as related to mental illness, further
complicating the job of police (Lamb et. al., 2002). Since its inception in 1988, CIT has
been implemented in over 3000 police services (Brown Cross et. al., 2014). CIT has
demonstrated limited effectiveness in settings lacking access to mental health services
(Canada et. al., 2010). CIT trained police are more likely to report increased calls with
PMI compared to non-CIT trained police (Canada et. al., 2012). CIT trained police are
more likely to refer or transport PMI to services and less likely to arrest a PMI (Compton
et. al., 2014b) and less likely to use force as a PMI demeanor became more resistant
(Morabito et. al., 2012). While CIT training is an integral part of mental health and

19
police collaboration, it is not the only mean of collaboration (Compton et. al., 2014a).
Identified barriers for implementation of CIT amongst police leadership include a small
workforce, financial cost, shift coverage, and substandard access to mental health
services (Compton, Broussard, Reed, Crisafio, & Watson, 2015). Kohrt and colleagues
(2015) highlight the example of Liberia, a post-war, impoverished country that recently
endured a near pandemic Ebola health crisis, yet authorities were able to effectively
customize CIT training. Cost savings of CIT did not have a sole beneficiary; rather
savings were spread across several mental health stakeholder services (El-Mallakh,
Kiran, & El-Mallakh, 2014). Thus, proactive interventions with limited resources can
improve services.
The Knoxville Model of collaboration involves a partnership between police and
a community agency (Borum et. al., 1998; Deane et. al., 1999) and has been identified as
the preferred time and resource-intensive choice (Brown Cross et. al., 2014; Shapiro,
Cusi, Kirst, O’Campo, Nakhost, & Stergiopoulos, 2015). Similar models involving
police and community agency collaboration are the Ride-Along Model (RAM)
(Boscarato et. al., 2014), the Police Ambulance Crisis Emergency Response (PACER)
model (Huppert & Griffiths, 2015), the Integrated Mobile Crisis Service (IMCS) out of
Halifax (Kisely, Campbell, Peddle, Hare, Pyche, Spicer, & Moore, 2010), and the
System-wide Mental Assessment Response Team (SMART) out of Los Angeles (Lamb
et. al., 1995). Health service and police partnership is more prevalent in Canada, as
Canada has a publicly funded health care system and stricter gun control laws, allowing
for greater mental health-police collaborative efforts (Coleman & Cotton, 2010). PACER
operates in a secondary response capacity, further reducing the risk to the mental health

20
professional attending with a designated police officer (Huppert & Griffiths, 2015). The
IMCS partnership comprised a designated plain-clothed police member with a mental
health professional (Kisely et. al., 2010). In over 80% of police calls for service
involving PMI, a Seattle-based collaborative model was able to refer to non-law
enforcement community agencies (Helfgott, Hickman, & Labossiere, 2016). PACER
provided ease of access to front line police officers, often negating the need for a mental
health apprehension (Huppert & Griffiths, 2015). During the study timeframe, only 27%
of PMI encountered by PACER required conveyance to an emergency department for
further assessment (Huppert & Griffiths, 2015). Co-responding mental health and police
partnerships were more likely to link PMI to community services, whereas CIT was more
prone to transport PMI to hospital (Shapiro et. al., 2015).
The Birmingham model of collaboration involves mental health professionals
working for the police department (Borum et. al., 1998; Deane et. al., 1999). A similar
model involving mental health professionals employed by the police department is the
Embedded model (Boscarato et. al., 2014). The Separate Response model comprises
informal collaboration between mental health and policing, where both stakeholders are
involved on the scene but arrive independently of one another (Boscarato et. al., 2014)
Challenges continue to exist in mental health and police collaboration. Poor
interagency relationships, limited information sharing, ineffective communication, lack
of professional respect, and lack of role clarity have been identified as barriers limiting
effective collaboration (Hollander, Lee, Tahtalian, Young, & Kulkarni, 2012). Role
distinction between the police officer and mental health professional (Lamb et. al., 2002),
attention to safety issues, ongoing collaboration, optics and role confusion between the

21
mental health professional and police have also been highlighted as impediments (Kirst
et. al., 2015). The need for subculture awareness within the police profession,
inefficiencies in patient pathways and long wait times in emergency departments place
strain on the collaborative relationship (Kirst et. al., 2015). Thus, ongoing stakeholder
communication is paramount for collaboration success (Lamb et. al., 2002).
2.4

Police Perception of Mental health
Western policing attitudes have evolved to acknowledge that mental illness is part

of policing (Chappell, 2010). Yet, police may view mental health professionals as ‘too
therapeutic’ (Augustin & Fagan, 2011). Police who have had greater exposure to calls
for service involving PMI report increased negative attitudes (Clayfield et. al., 2011)
including pessimism and the belief that PMI are dangerous and threatening (Krameddine,
DeMarco, Hassel, & Silverstone, 2013). Boyd and colleagues (2015) noted police
correlated violent acts to a mental health diagnosis. For example, police may surmise
that an individual with a diagnosis of schizophrenia, may be dangerous, while at the same
time viewing that same individual as being less responsible for their actions due to their
diagnosis, thereby becoming an object of pity (Watson, Corrigan & Onnati, 2004). Even
when physical force was required, CIT trained police were less likely to arrest PMI
(Compton et. al., 2014b) and less likely to use force overall, even identifying the use of
physical force as less effective than non-physical actions (Compton et. al., 2011).
Traditional and cultural differences within the professions of police and mental health
professionals are often cited as an obstacle (Augustin & Fagan, 2011). An increased
level of knowledge pertaining to mental health amongst police members results in
increased empathy for PMI (Bonfire et. al., 2014), while training and preparation

22
regarding mental health increases confidence and comfort (Borum et. al., 1998).
Preexisting stigma may negatively taint police attitudes toward PMI (Bonfire et. al.,
2014; Clayfield et. al., 2011); however, as Cotton (2004) notes police do not tend to
display high levels of authoritarianism or social exclusion attitudes towards PMI.
Increased comfort and knowledge of mental health decreases the likelihood of force to be
used (Bonfire et. al., 2014). Disparaging attitudes towards mental illness is thought to be
associated with negative behaviors (Clayfield et. al., 2011). Improved knowledge of
mental illness contributes to shifts in attitude and dispelling stigma from previously held
beliefs (Hanafi, Bahora, Demir, & Compton, 2008). Changes in police attitudes are
described as a precursor to changes in their behavior (Bonfire et. al., 2014); however
interestingly, behaviors can be changed alone without a change in attitude (Krammeddine
et. al., 2013). The attitude that PMI are dangerous can lead to the overuse of the TASER
as TASER research has been noted to vary, often minimizing negative outcomes
potentially leading to overuse (O’Brien & Thom, 2014).
The CIT model ranked the highest of the three main (Memphis, Birmingham, &
Knoxville) mental health-police collaborative relationships amongst police; all Memphis
CIT apprehension were brought to one main emergency department where access to
services was streamlined and efficient (Borum et. al., 1998). CIT knowledge was
deemed as useful for police in differentiating between drug/alcohol behaviors from
symptoms of mental illness (Canada et. al., 2010). Memphis CIT did not rely on onscene community stabilization, while Birmingham and Knoxville models did not
exclusively rely on emergency department intervention, thus their perceptions of mental
health services were viewed as moderate and low respectively (Borum et. al., 1998).

23
Following CIT training, police were more likely to endorse biological causes of
schizophrenia versus sociocultural and socioeconomic causes (Demir et. al., 2009) and
increased knowledge and attitude changes resulted in increased empathy for PMI (Hanafi
et. al., 2008). Furthermore, CIT training affected police beliefs positively, placing
beliefs in line with those of mental health professionals (Demir et. al., 2009.
PMI identified the ride-along model (RAM) as the preferred mental health
response when compared to other models (Boscarato et. al., 2014). Furthermore, all PMI
indicated a preference for informal crisis intervention through non-police, already
established supports (Boscarato et. al., 2014). The desired theme of greater
interdisciplinary collaboration between police and mental health was identified
(Boscarato et. al., 2014) and clients seen by the RAM-type model were noted to have
greater engagement with outpatient services compared to clients with no RAM-type
model (Kisely et. al., 2010).
2.5

Therapeutic communication
Communication is an interactive process, requiring attention and investment into

the conversation (Greenstone, 2004). Interpersonal communication requires sending and
receiving information between two or more people (Matusitz, 2013). Psychiatric nurses
and police share similar skillsets taught in the CIT curriculum (Ellis, 2014). A PMI
based theme of satisfaction was related to the establishment of a strong therapeutic
relationship (Barker et. al., 2011) yet mental health professional communication may be
lacking in basic Active Listening Skills (ALS) as PMI may feel more empathy and
validation via communication from a peer (Forchuck et. al., 2010). Communication has
three components: a content message; a feeling message; and a meaning message

24
(Greenstone, 2004). According to Boscarato and colleagues (2014), increasing ALS over
mental health knowledge should be emphasized. Thus, time and ALS enabled
clarification of PMI needs resulting from police calls for service and are crucial for
success (Canada et. al., 2012). Clarification, effective questioning, listening, and
nonverbal communication are all components of effective communication (Greenstone,
2004). The use of empathy, validation and respect for the PMI transcends the
professional designation (Kirst et. al., 2015). A lack of communication or the presence of
miscommunication may further serve to propagate the development of psychosis in a
PMI (Gregory & Thompson, 2013). The importance of verbal de-escalation skills is
inherent to police success with PMI (Canada et. al., 2010) as verbal de-escalation skills
are crucial for diverting PMI away from jail often, through the resolution of emotional
dysregulation (Compton et. al., 2014a). For example, due to training in verbal deescalation skills Compton and colleagues found that verbal engagement and negotiation
were more effective in CIT trained police, and on-scene resolution was more feasible
when no force or lower force was used (Compton et. al., 2014b).. CIT trained police may
interpret resistive demeanor as a symptom of illness and implement de-escalation
techniques (Morabito et. al., 2012). Application of de-escalation skills assisted police in
putting PMI at ease, having greater control over unpredictability, and reducing the risk of
officer injury (Hanafi et. al., 2008). Compton, Broussard, Hankerson-Dyson, Krishan, &
Stewart-Hutto (2011) also note that while CIT training did not impact empathy or
psychological mindedness, these may be person-specific stable traits and that some police
are better suited for mental health work than others.

25
Crisis Negotiator Teams are viewed as a complement to tactical police
intervention; recognizing the value of mental health professionals resulted in Crisis
Negotiator Teams as the primary intervention with a tactical response as an adjunct
option (Augustin & Fagan, 2011). Crisis negotiators borrow theory from mental health;
the Structured Tactical Engagement Process model is based on the transtheoretical stages
of change model applied in addictions treatment (Grubb, 2010). Furthermore, successful
negotiation depends upon exceptional communication skills (Matusitz, 2013).
2.6

Post-Mental Health Apprehension Disposition
Positive therapeutic relationships and support contribute to an increased ability for

community stabilization for PMI. Proactive stabilization service implementation is
associated with higher rates of community stabilization (Barker et. al., 2011). Data
specific to CIT and individual PMI outcomes are not readily available, limiting future
research opportunities in this area (Bonfire et. al., 2014). Existing literature focuses on
the recognition of mental health issues by police with less attention given to PMI
stabilization post-police involvement, often leaving the PMI unable to access services
(Bonkiewicz et. al., 2014). In one example from Edinburgh, Scotland, the Crisis
Resolution and Home Treatment (CRHT) team provides a 24/7 service acting as the
exclusive ‘gatekeeper’ of inpatient beds. In order for PMI to be admitted to an inpatient
bed CRHT, must first be involved (Barker et. al., 2011). Psychotic symptoms such as
impaired insight, treatment apathy, disruptive behavior and other factors impeding
community stabilization were associated with higher likelihoods of inpatient admissions
(Hasselberg, Grawe, Johnson, Slatyte-Benth, & Ruud, 2013). Average inpatient
admissions decreased by nearly 25% in the year since CRHT implementation and the

26
average length of stay was reduced by over nine days (Barker et. al., 2011). Conversely,
when community stabilization options are limited, many CIT-trained officers have no
choice but to bring PMI to emergency departments (Canada et. al., 2010). Patient care
and outcomes are improved with police and emergency department staff members
speaking a common language (Hoffman et. al., 2016). Access to acute mental health
services and appropriate community stabilization options decreases the probability of
requiring inpatient admission (Cotton et. al., 2007). A lack of assertive community
support correlates with high inpatient admission rates (Hasselberg et. al., 2013). Of PMI
brought to hospital, those brought to hospital by police and family share similar
characteristics, however PMI brought in by family scored higher on the Global
Assessment of Functioning, indicative of a milder severity of illness (Broussard et. al.,
2010). Reasons behind police apprehension are different from reasons for inpatient
admission (Hoffman et. al., 2016). Emergency department staff indicated many of the
PMI brought to the emergency department by police would be discharged, causing
emergency department staff to question why the PMI were brought to the emergency
department in the first place (McKenna et. al., 2015). The UK Mental Health Act section
136 permits police to detain an individual for up to 72 hours to facilitate a mental health
assessment; the individual must be brought to a ‘place of safety’, of which there are five
general options – only two of which are healthcare facilities (Holmes, 2014). Following
section 136 apprehensions, inpatient admission rates are 20% (Holmes, 2014). Frequent
discharges post police mental health apprehension resulted in police pursuing criminal
charges against PMI, as the PMI would be handled in a more systematic and predictable
manner (Lamb et. al., 2004). For police, treatment of illness necessitated criminal

27
charges; post-incarceration, compliance with treatment was highly probable as it was a
legal condition of release (Lamb et. al., 2004). Disposition of a call or service involving
PMI is contingent on treatment accessibility and police knowledge regarding available
mental health options (Ritter et. al., 2011). Health information facilitated dispositions in
calls for service (Lamb et. al., 2002). Teller and colleagues (2006) noted a decrease in
police transports of PMI to psychiatric emergency services was noted, possibly due to the
effectiveness of CIT de-escalation training.
2.7

Overview of PACT and Urgent Services (US) Consultation
A visual representing the flow of PACT consultation is presented in figure 1.1

(see Appendix C). PACT operates from 0700-0100 every day of the week, while US
operates 24 hours a day, seven days a week. To facilitate EPS access to PACT and US
services, a direct number has been provided to all of EPS. During the PACT hours of
operation from 0700-0100, the PACT number will go directly to the EPS PACT member
on duty. From the hours of 0100-0700, the PACT number will go directly to the US
team. This 24-hour coverage ensures a one-stop solution for EPS members who
encounter a PMI with an addictions or mental health concern.
There is heavy literature that is American-based. Two different systems of
healthcare exist between the privately-funded American model and the publicly-funded
Canadian model. Systems and services are set up differently, thus there is not one ideal
model of police and mental health partnership that can be universally applied to any
setting.

28
Chapter 3 - Methods
The secondary data used in this research was compiled by AHS Protective
Services (PS) during the entirety of the 2016 calendar year from all four designated
facilities in the Edmonton Zone. The data was originally tracked as a means of quality
improvement for the Urgent and Intensive Services portfolio within the AHS Edmonton
Zone. Access to the non-patient identifying numerical data was granted by Pamela
Coulson, the Director of Urgent and Intensive Services.
AHS is the largest public addiction and mental health service in Alberta. As such
AHS maintains statistics and information on access, flow, and type of concern for service
consumers in the province. The data gathered by AHS is, at times, used for program
evaluation, planning, quality improvement, and responsiveness to emerging trends. From
this information, AHS was solicited to provide data specific to research questions in the
2016 calendar year. All analysis is limited to this calendar year.
Polit and Beck (2012) noted that secondary analysis as using existing data to
solve new queries and investigate new hypotheses. Furthermore, Polit and Beck (2012)
postulated researchers who would be performing secondary analyses must be able to
identify and access suitable databases. Benefits for secondary data use are cost and time
savings whilst the disadvantages of using available data are limited for specific research
questions and hypotheses (Cheng & Phillips, 2014). Polit and Beck (2012) noted a
likelihood that a secondary data set is deficient in some way. The data required for this
research was accessible through the Director of Urgent and Intensive Services with AHS.
Attrition is a non-issue in a nonprobability study using convenience sampling. As the
data has already been gathered by Urgent and Intensive Services and AHS Protective

29
Services, the study cannot lose participants during the course of data collection.
Participants could not be disqualified from the study for any other reasons. There is a
noted gap in the current knowledge base which is why the analysis of readily available
secondary data is used.
A quantitative descriptive research design using chi-square analysis was used to
compare frequencies. Once receiving the data, it was further delineated to reflect the
three research questions. A total of 2479 PMI had been apprehended in the City of
Edmonton in the 2016 calendar year. The secondary data was reviewed and three
research questions were developed. Resultantly a chi-square analysis was completed to
indicate the clinical significance of the occurrences reflected in the secondary data.
Individual observations are independent of one another. There are more than five
observations in each expected cell. The data used is normally distributed and all
assumptions have been fulfilled.
As per the aforementioned conditions and data, it is prudent to explore ways that
secondary data can be translated to informed practice. AHS has a practice of quality
improvement and assurance. Data was provided on the basis of this.
Disposition checks (see Appendix A) of MHAA by EPS are collected by AHS
Protective Services at each of the four hospital ED sites in Edmonton.
3.1

Ethics
Ethics approval to conduct this study was granted by the Brandon University

Research Ethics Board (BUREC), and AHS. This study involved analysis of non-patient
identified secondary data compiled by AHS for administrative purposes, thus no personal
information regarding PMIs was required. Data from January 1, 2016 to December 31,

30
2016 included whether or not Urgent Services or PACT were involved prior to MHAA,
whether or not the individual apprehended was admitted or discharged, and from July 1,
2016 to December 31,2016 data regarding substance related MHAA was gathered.

3.2

Pathway to Patient Care
The process of PACT for this research is presented in figure 1.1 (See Appendix

C). The process is an illustrated patient pathway to care. It is designed from the
literature review findings and the proposed research in mind. PACT operates from 07000100 every day of the week. US operates 24 hours a day, seven days a week.
To facilitate EPS access to PACT and US services, a direct number has been
provided to all of EPS. During the PACT hours of operation from 0700-0100, the PACT
number will go directly to the EPS PACT member on duty. From the hours of 01000700, the PACT number will go directly to the US team. This 24-hour coverage ensures
a one-stop solution for EPS members who encounter a PMI with an addictions or mental
health concern.
The purpose of these variables is to identify the frequency and acuity of
addictions and mental health calls for service to EPS. The effect of prompt access versus
no access to crisis type mental health community-based services can be compared and
contrasted. Lastly, the emphasis of a safe end to a call for service can be highlighted with
the amount of PMI discharged following a MHAA.
Data comprises three sections: A, B, & C. Inclusionary criteria for Section A (see
Appendix D) comprised all individuals (child, adolescent, and adult) apprehended during
the year-long timeframe. No exclusionary criteria were present in Section A. The sole

31
limitation to this data is that PACT and US do not provide clinical intervention for child
and adolescent psychiatry.
The inclusionary criteria for Section B (see Appendix D) included all addiction
and mental health calls for service for EPS and US. No exclusionary criteria were
present in Section B. The sole limitation for Section B data is that EPS calls for service
included child and adolescent populations, whereas PACT and US involvement did not
include child and adolescent populations.
The purpose of Section B variables is primarily focused on EPS’ ability to divert
PMI from a MHAA to the ED compared to US’ ability to divert PMI from the ED.
Additional variables include admission following apprehension, and discharge home
following apprehension. It should be noted, admission following apprehension would not
be the sole factor in determining whether or not a MHAA was the most appropriate
disposition choice. Yet admission following apprehension could be indicative of EPS’
ability to accurately assess the severity of illness of the PMI.
The purpose of Section C (see Appendix D) variables is to reflect the prevalence
of substance related calls for service. EPS rely on formulating a safe and effective
disposition plan for a call for service. The ED is a no-refusal, always open, universally
accessible service for EPS to end a call for service in a safe manner. The prevalence of
substance related calls for service resulting in MHA apprehension may be indicative of a
lack of other means to end a call in a safe manner.
The gathered data would include the disposition following MHAA (PMI
admitted/not admitted) and whether or not US or PACT was consulted prior to
apprehension. Additional data had been gathered from July 1, 2016 until December 31,

32
2016 regarding substance related (see Appendix D) apprehensions was gathered.
Specifically, whether or not substance use was a primary reason for apprehension, and
the disposition following MHAA.
The accumulated data used in this research is from the 2016 calendar year. The
data was gathered by Alberta Health Services Protective Services members at each of the
four designated facilities accepting people apprehended on a MHAA.
3.3

Research Design
A retrospective quantitative research design using secondary data was used. The

non-identifying data used in this study was captured by AHS Protective Services from the
2016 calendar year. The data was accessible, appropriate, and relevant for use.
Research Question 1
Whether the Knoxville Model (PACT) and Separate Response Model (US + EPS
patrol) working together have a greater effect in diverting PMI away from the ED
compared to no models?
Null Hypothesis 1
There is no difference in diversion from the ED to community addiction and
mental health services between using the models (Knoxville Model and Separate
Response Model) or without the model.
Research Question 2
Does the Knoxville Model or Separate Response Model have a greater ability to
divert PMI away from the ED to community addiction and mental health services
compared to the Separate Response Model?
Null Hypothesis 2

33
There is no difference between using the Knoxville Model or Separate Response
Model in diverting PMI away from the ED to community addiction and mental health
services.
Research Question 3
Based on known etiology related to stigma in addiction and mental health,
whether the presence of substance related concern would have influence or have clinical
significance in relation to admission to hospital warrants investigation. Is there a
difference in disposition between substance related and non-substance related MHAAs?
Null Hypothesis 3
There is no difference in disposition between substance related and non-substance
related MHAA.
The sample size for research question 1 incorporates all dispositions following
MHAA from January 1, 2016 to December 31, 2016. The sample size for research
question 2 was from April 1, 2016 to December 31, 2016. The sample size for research
question 3 was from August 1, 2016 to December 31, 2016. Two possible disposition
options exist: either the apprehended individual is admitted as an inpatient, or they are
discharged home. The data for this research included every individual apprehended via
Form 10 by EPS in the 2016 calendar year. This data captured the disposition following
the MHAA, and whether or not US or PACT was consulted prior to the MHAA.
Chapter 4 – Data Analysis and Findings
The research was completed based on a normal distribution of chi with a clinical
significance of .05 and df of 1. A chi-squared analysis was used to compare frequencies

34
of categorical data using a 2x2 table. A chi-squared test as used to determine whether a
difference between the variables was present.
Table 1
Critical Values for the 2 Distribution

df

.10

.05

.02

.01

.001

1

2.71

3.84

5.41

6.63

10.83

2

4.61

5.99

7.82

9.21

13.82

3

6.25

7.82

9.84

11.34

16.27

4

7.78

9.49

11.67

13.28

18.46

5

9.24

11.07

13.39

15.09

20.52

Research Question 1: (January – December 2016)
Whether the Knoxville Model (PACT) and Separate Response Model (US + EPS
patrol) working together have a greater effect in diverting PMI away from the ED
compared to no models?
Table 2

Type

Admitted to ED

Discharged from ED

Total

With Mental Health

413

453

866

Without Mental Health

361

1252

1613

Total

774

1705

2479

35
In this study 361 PMI brought to the ED via MHAA by police only were admitted
to an inpatient unit.
2 (1, n = 361) = 40.38, p  .05. 40.38  3.84.
Comparatively, 413 PMI brought to the ED via MHAA by police assisted by a
mental health clinician were admitted to an inpatient unit.
2 (1, n = 413) = 75.20, p  .05. 75.20  3.84.
Statistical significance is present for a PMI brought to ED via MHAA by either
police only
(2 = 40.38; 40.38  3.84), or via MHAA with the involvement of a mental health
clinician and police (2 = 75.20; 75.20  3.84).
The odds ratio of a police only MHAA admitted to hospital relative to a MHAA
with the involvement of a mental health clinician was 0.316. A police-only MHAA was
0.316 times less likely to be admitted in comparison to a MHAA with the involvement of
a mental health clinician.
A MHAA with the assistance of a mental health clinician was over 3 times more
likely (3.16) to be admitted to hospital in comparison to a Police Only MHAA.
Discharged post MHAA:
In this study 1252 PMI brought to the ED via police only (n = 1252) were
discharged from the ED following a MHAA.
2 (1, n = 1252) = 18.33, p  .05. 18.33  3.84.
Comparatively, 453 PMI brought to the ED via MHAA by police, with mental
health assessment and consultation were discharged from the ED following a MHAA.
2 (1, n = 453) = 34.14, p  .05. 34.14  3.84.

36
There is statistical significance to indicate an increased likelihood of discharge
from the ED regardless if the PMI is brought to the ED by police only or following a
MHAA with the assistance of a mental health clinician. The Pearson Chi-Square was
168.091. With the degrees of freedom being 1 and an alpha level of .05, there is strong
evidence the difference between the groups is not due to chance. 168.091  3.84.
The experimental hypothesis of: Collaboration between a Knoxville Model and
Separate Response Model will result in an increase in PMI being diverted from EDs to
community addictions and mental health services, was supported by the findings. More
PMI brought to ED via MHAA by police-only get discharged from the ED compared to
MHAAs with the assistance of a mental health clinician. All chi values calculated in
research question 1 remain statistically significant when compared to an alpha level of
.001.

Research Question 2: (April – December 2016)
Does the Knoxville Model or Separate Response Model have a greater ability to
divert PMI away from the ED to community addiction and mental health services
compared to the Separate Response Model?
Table 3

Type

Admitted

Diverted

Total

Knoxville Model (PACT)

189

3603

3792

Separate Response Model

493

4802

5295

Total

682

8405

9087

37

189 PMI brought to the ED via PACT MHAA were admitted to an inpatient unit.
2 (1, n = 189) = 32.11, p  .05. 32.11  3.84.
Comparatively 493 PMI brought to the ED via Urgent Services with EPS MHAA
were admitted to an inpatient unit.
c2 (1, n = 493) = 23.00, p  .05. 23.00  3.84
3603 PMI who encountered PACT at the time of crisis were diverted from the
ED.
2 (1, n = 3603) = 2.62, p  .05. 2.62  3.84
Comparatively, 4802 PMI who encountered Urgent Services with EPS at the time
of crisis were diverted from the ED.
2 (1, n = 4802) = 1.87, p  .05. 1.87  3.84
The odds ratio indicated a PMI is 96.57 times more likely to be diverted from
hospital via the Separate Response Model than through the Knoxville Model. Conversely
the odds ratio of a PMI being diverted from hospital via the Knoxville Model as opposed
to the Separate Response Model is 0.010. The Pearson Chi-Square value was 59.581.
With the degrees of freedom being 1 and an alpha level of .05, there is strong evidence
the difference between the groups is not due to chance. 59.581  3.84. When compared
to an alpha level of .001 the chi value remained statistically significant. 59.581 > 10.828.
There is statistical significance to indicate an increased likelihood of diversion
from the ED if the PMI encounters the Separate Response Model at the time of crisis.
The experimental hypothesis of: One mental health consultation model (e.g. Knoxville
Model (PACT) or Separate Response Model (US with EPS)) will be better able to divert

38
PMI away from the ED, was supported by the findings. The Separate Response Model is
more successful at diverting PMI away from the ED compared to the Knoxville Model.

Research Question 3: (August – December 2016)
Based on known etiology related to stigma in addiction and mental health,
whether the presence of substance related concern would have influence or have clinical
significance in relation to admission to hospital warrants investigation. Is there a
difference in disposition between substance related and non-substance related MHAAs?
Table 4

Type

Admit from ED

Discharge from ED

Total

Substance related MHAA

170

406

576

Non-Substance related MHAA

169

239

408

Total

339

645

984

169 PMI with a non-substance related MHAA were admitted to an inpatient unit.
2 (1, n = 169) = 5.74, p  .05. 5.74  3.84.
Comparatively, 170 PMI with a substance related MHAA were admitted to an
inpatient unit.
2 (1, n = 170) = 4.06, p  .05. 4.06  3.84.
The odds ratio of a substance related MHAA being admitted is 0.59 times more
than a non-substance related admission.

39
239 PMI apprehended on non-substance related MHAA were discharged from the
ED.
2 (1, n = 239) = 3.02, p  .05. 3.02  3.84.
In comparison 406 PMI apprehended on substance related MHAA were
discharged from the ED. 2 (1, n = 406) = 2.14, p  .05. 2.14  3.84.
The odds ratio of a non-substance related MHAA is 1.69 more times likely to be
admitted than a substance related MHAA. The Pearson Chi-Square value was 14.996.
With the degrees of freedom being 1 and an alpha level of .05, there is strong evidence
the difference between the groups is not due to chance. 14.991  3.84
There is no statistical significance to indicate a PMI apprehended on a substance
related MHAA is more likely to be discharged from the ED. The experimental
hypothesis of: There is a difference in disposition between substance and non-substance
related MHAA was not supported in the findings.
The involvement of a mental health clinician influenced whether or not PMI
apprehended on a mental health apprehension were admitted to hospital. PMI were more
likely to be discharged from an emergency department without the involvement of a
mental health clinician. In comparison, the informal Separate Response Model was more
effective than the formal Knoxville Partnership was in diverting PMI away from the
emergency department. Substance related and non-substance related apprehensions had
no bearing on whether or not the PMI was admitted to hospital, or discharged from the
emergency department.
Prompt access to a mental health clinician at the time of crisis enables police to
better ensure proper care is being delivered to the subject of the call for service. In

40
addition to greater likelihood of safe and effective community stabilization through
linkage to appropriate services, informal partnerships may prove more cost-effective for
police services than would a formal partnership or formal training. Regardless of any
substance use or not, there is no indication substance use affects either admission or
discharge from hospital rates. Apprehension and admission to hospital is based on
presenting symptoms, not the underlying etiology of those symptoms.

Chapter 5 - Discussion
Police members are tasked with making dangerous high-stakes decisions with
potentially fatal outcomes (Rosenbaum, Tinney, & Tohen, 2017). Mental health crises
require both mental health and police professionals to combine professional skillsets to
recognize and mitigate risk factors (Lamb et al., 2004). Collaboration between
psychiatry and police is needed more than ever (Rosenbaum et al., 2017) yet the manner
in which effective collaboration is measured remains open to interpretation. Calls for
service to police involving severe mental illness have increased and have caused a
notable impact on police, the public, and PMI themselves (Hensen et. al, 2016).
Professional humility is imperative. Understanding gaps in knowledge may better
enable police members to deliver client-centred care. The mental health data collected by
police may be misleading due to police agencies having an obvious primary focus on
public safety and crime (Rosenbaum et al., 2017). Police members are tasked with
mitigating both criminal and social crises. A criminal crisis may be straightforward given
police members’ subject matter expertise in same. Mitigating a social crisis as the result
of acute mental illness symptomology may be beyond the comfort level of the police

41
member. Police members catch ‘the bad guy’, solve crimes, and are not largely known
for mitigating mental health crises.
Communities with strong mental health and police collaboration have reduced
mental health apprehensions, arrests, jail time, and lawsuits resulting in cost savings for
both stakeholders (Cowell, Hinde, Broner, & Aldridge, 2013). The results of this
research identified an informal partnership (Separate Response Model) as being more
effective in diverting PMI away from emergency departments than a formal partnership
(Knoxville Model). Formal training may not be as effective in comparison to stakeholder
partnerships between police services and community/government services.
The Albuquerque Police Department’s Crisis Intervention Team (CIT) training
comprises three themes: inclusive collaboration, training, and coordinated response
(Rosenbaum et al., 2017). All of these themes are informally used in the PACT
partnership between EPS and AHS.
5.1

Inclusive collaboration
Effective stakeholder communication is imperative in collaborative efforts. EPS

and AHS share a memorandum of understanding wherein both stakeholders are able to
disclose relevant information to one another provided an element of risk exists, for
pragmatic purposes. The Health Information Act of Alberta (2000) provides custodians
of healthcare information to disclose select limited information to a police service if
“…the disclosure will protect the health and safety of Albertans” (Health Information Act
of Alberta, 2000, p. 30). EPS may not frivolously request health information on a subject
before or following their involvement. AHS partners may not inquire into confidential
police information if no clinical indication to do so is present.

42
PACT began in Edmonton in 2004 as a one-team pilot program. Since that time,
the program has expanded to a total of seven teams working alternate shifts, providing
near 24-hour coverage to the City of Edmonton. The PACT program has evolved in
response to varying and newly identified needs for each respective stakeholder. Initially
PACT operated in a secondary response capacity. PACT members would be consulted
by on-scene patrol members or would be sent police files flagged for review. AHS
administrators noted missed opportunities to engage PMI in services at the time of most
need and EPS administrators noted excessive MHAA wait times in the ED. The mandate
of PACT evolved into a first-responder capacity. As of September 2016, EPS policy
changed, requiring all potential MHAA to be vetted by PACT or US (P. Coulson,
Director of Urgent and Intensive Services, personal communication, June 14, 2017).
Similarly, a Mobile Crisis Rapid Response Team (MCRRT) was created in 2013
in the city of Hamilton, Ontario. MCRRT comprises a partnership between police and
mental health that responds to emergency calls for service as first responders (Fahim,
Semovski, & Younger, 2016). The aim of MCRRT is to divert PMI from unnecessary
ED presentations and connect them to safe and effective community resources (Fahim et
al., 2016). Bringing the right services to the right people at the right time can result in
effective client care and decreased financial cost to both healthcare and police
stakeholders.
A point of caution must be raised not to equate diversion from the ED as the
ultimate goal. An excessive focus on ED diversion may result in acuity of illness and
risk potential being minimized, if not overlooked entirely. A presentation to the ED via
MHAA is intended to ensure a clinical assessment as a means to ensure access to

43
potential treatment for PMI. A further point of caution would be for police members
avoiding ‘dictating care’ for PMI. Police members feared that PMI would not get the
care they needed upon presentation to an ED (Kubiak et al., 2017; Wood & Watson,
2017). Inpatient admission does not equate to proper clinical treatment. Dependent on
the circumstances of the PMI, admission to an inpatient setting may be contraindicated.
Receiving help is not contingent on being admitted to an inpatient setting. Moreover,
what may present as a mental health crisis at face value may in fact be the manifestation
of a life-threatening medical illness. Delirium, a secondary condition to one or more
underlying medical complications, may be disregarded in absence of a formal mental
health history leading to poor health outcomes if not death. A sudden dramatic departure
from baseline presentation may be indicative of an underlying and potentially fatal
organic pathology. In police education, an overemphasis on mental health recognition
may be detrimental. This may limit the amount of information police members would
collect, potentially overlooking an obvious medical concern and rationalizing the
behavior from a mental health perspective.
The results of this research identified a discrepancy in diversion rates from the ED
between the Separate Response Model (informal partnership between Urgent Services
with Patrol) and the Knoxville Model (formal partnership between AHS and EPS).
Statistical significance, albeit with a less robust chi-square analysis, indicating an
increased likelihood of diversion from the ED was present with the involvement of the
Separate Response Model (Urgent Services with Patrol). Given the discrepancy between
diversion from ED rates between the Separate Response Model (Urgent Services with
Patrol) and the Knoxville Model (PACT), further issues become apparent.

44
There may be a difference between a mental health crisis and a psychiatric
emergency. An emergency with a psychiatric etiology requires immediate response
whereas a mental health crisis may be less acute in comparison, requiring a timely
response. The lack of terminology in the literature to delineate between a mental health
crisis and a psychiatric emergency is concerning. There is currently no language present
to describe the two terms. In the event Urgent Services would receive a call requiring
immediate response, it would be deferred to EPS. Should the call to Urgent Services not
require an immediate response, but a timely response – Urgent Services would be able to
follow up with EPS, if a likelihood for risk or MHAA was present. Police members have
so many responsibilities with complex cases beyond criminal behavior. They are tasked
with protecting public safety and have limited resources available. Judgment calls need
to be made in a timely manner with dire consequences if the police members are wrong.
As a first-responder service, it could be assumed a mental health related call for
service to EPS would fit a higher acuity level. The mental health call for service could be
dispatched to an available PACT team. Given the assumed heightened acuity level the
opportunity for de-escalation followed by safe and effective community stabilization may
be limited. By virtue of a higher acuity call for service, the lack of safe and effective
means of stabilization may result in a MHAA. The discrepancy between the disposition
outcomes of the Separate Response Model (Urgent Services with Patrol) and the
Knoxville Model (PACT) may not be due to clinical expertise, rather due to the nature of
acuity in the calls for service.
5.2

Mental Health Training for Police

45
Fahim et al (2016) noted the 40-hour CIT training MCRRT police members
receive may not always adequately prepare its police members in de-escalation
techniques. Significant variations in content, design, and delivery of mental health
training for non-mental health trained professionals resulted in a lack of clarity regarding
best practice (Booth et al., 2017). Interestingly in Edmonton, PACT police members do
not receive any formal mental health training. Potential PACT police members are
selected based on individual merit, seniority, and personal suitability for the position.
Moreover, an identified interest in addictions and mental health must be present. Interest
is first shown by volunteering for coverage for when a regular PACT police member is
away from their regular shift rotation. Education is done on an informal basis, with the
PACT mental health therapist providing teaching prior to a call for service and enabling
mutual reflective practice to occur following a successful disposition. Police
stakeholders would incur training costs in CIT style education. Informal education for
the police member through either a formal or informal partnership is done at no out-ofpocket cost for either stakeholder. The police member receives informal education from
their mental health clinician through the lived experience of working in a joint
partnership.
Knowles (1968) theory of adult learning principles described adult-learners as
autonomous, goal-oriented, seeking relevant learning, having life experience, are
practical in nature, and need respect. Self-selection through volunteering is done by the
potential PACT police member, providing autonomy. Potential PACT police members
are goal-driven to gain an increase in evidence-informed knowledge, to later incorporate
into evidence-informed practice during mental health calls for service. A longstanding

46
healthy collaborative partnership between EPS and AHS fosters this development.
Conversely, PACT mental health therapists gain a base of knowledge and understanding
of the professional world of their police partners.
The tenure for a PACT police member is limited to four years. The police
position in PACT is deemed a ‘preferred position.’ Police members start their careers in
the ‘non-preferred position’ of patrol. Within five years of starting their careers, police
members may apply for an internal transfer to another area within the service. Select
non-patrol positions within EPS are regarded as competitive and thus, ‘preferred
positions.’ The four-year time period provides the PACT member to become well versed
in assessment skills, knowledge of illness, and knowledge of community resources other
than simply an ED presentation. The four-year tenure in the ‘preferred position’ of
PACT is limited. Following the end of their PACT tenure, the police member would then
transfer back to a ‘non-preferred position’ for a pre-established timeframe before
becoming eligible for applying for another ‘preferred position.’ During the four-year
time period, the PACT member informally disseminates their knowledge and skill to EPS
patrol members. On departure from their tenure at PACT the police member retains
skills and knowledge, thereby further disseminating skill and knowledge in their
respective postings. This informal knowledge dissemination may account for a greater
number of PMI being diverted from the ED through the Separate Response Model to safe
and effective stabilization through prompt access to community-based services.
5.3

Coordinated Response
Balfour, Winsky, & Isely (2017) noted that the Tucson Mental Health

Investigative Support Team (MHIST) police members drive unmarked cars and wear

47
plain clothes in an effort to mitigate stigma and likelihood of behavioral escalation that
may occur from seeing a uniformed police member. Symptoms of severe mental illness
or acute substance intoxication, may include paranoia and persecutory ideations. PMI
who are paranoid due to their illness may very likely be suspicious of the legitimacy of a
plain clothes police member. A plain clothes police response may decrease the optics of
police presence, yet it can equally breed further paranoia with PMI. The potential for a
paranoid client to request a uniformed police member’s badge and photo identification
can be diagnostically significant. The presence of persecutory ideations may be a key
factor in a PMI approaching police assistance. PMI may be comforted by the presence of
a uniform as it can be associated with safety and security. Moreover, a plain clothes
approach may indirectly contribute to the existing stigma of mental health, inferring to
PMI that they are treated in a manner different than the rest of the general population.
Stigma may be as equally prevalent to police services as it is for people living with
mental illness. Health is health, be it physical health or mental health.
PACT operates year-round with operational hours between 0700-0200. During
the five-hour lapse, Urgent Services staff remain available for immediate consultation for
police. During this time, Urgent Services staff fields calls from the general community in
addition to calls from police. During acute periods, calls to PACT may be diverted to
Urgent Services as one PACT team on duty may be unable to adequately field the calls
for service. Calls diverted from PACT to Urgent Services are non-emergent and have a
police presence. Although not a formal site, an informal ‘no refusal’ policy with regard
to phone consultation exists. Wood & Watson (2017) noted collaborative partnerships

48
that include co-responder teams and a ‘hotline’ staffed by mental health professionals for
use by police when PMI are encountered in patrol.
Police are tasked with ending a call for service in a safe manner. Regardless of
the etiology of the psychiatric symptoms, the presence of symptoms of illness is the
factor requiring action. Interestingly neither admission nor discharge rates from hospital
are correlated to substance use, or no substance use. The results of the research are
reassuring as despite the reason, if a PMI requires an admission – they will receive an
admission regardless of substance use. The research findings may serve to provide
reassurance to both mental health and police stakeholders. A substance related MHAA
would have received the same level of care as would a non-substance related MHAA as
neither the presence nor absence of substance use presented as a factor influencing either
admission or discharge. Equally it should be reiterated that the ED may not be an
appropriate disposition for a PMI. Attendance to an ED will provide an assessment and
alleviate the police member from liability, yet the same assessment may be provided by a
mental health profession at the time of crisis, at the home of the PMI. A mental health
assessment at the home of the PMI may be diagnostically telling, compared to the same
assessment being completed in the controlled environment of the ED.
Horspool, Drabble, & O’Cathain (2016) remarked no universal approach for
mental health and police collaboration exists and the geography and population size of
the service area should be considered. In a systematic scoping review, Parker et al.,
(2018) noted thirteen distinct models of interagency collaboration were identified albeit
similarities occurred within agency composition. Working within ones means is
imperative. MHIST has a focus on sharing information with healthcare providers rather

49
than requesting information (Balfour et al., 2017). Co-responding teams were 2.3 times
more likely to bring PMI to ED compared to police only teams (Lamanna et al., 2018)
although this is indicative of recognition of symptoms of illness, not necessarily a
clinically warranted decision.
Research findings indicated statistical significance of discharge from the ED in
general, albeit done via the less robust chi-square analysis. The ED is a universal, norefusal, consistently accessible resource. The statistical prevalence of significant
numbers of PMI being discharged from the ED post MHAA suggests a need for
disposition options apart from the ED itself.

5.4

Implications and Future Research Opportunities
For the purposes of this research, secondary data was analyzed. Future research

opportunities exist in research based on intentional data accumulation as compared to
analyzing already existing data. The implication for same would allow for a variety of
focused research questions specific to the mental health and police partnership.
An area for future research could examine primary reasons behind a MHAA,
beyond the current substance or non-substance related MHAA. Additionally, future
research may examine the prevalence of physical health related MHAA. Symptoms of
physical illness (e.g. delirium, hypoglycemia) can mirror psychiatric-based symptoms of
illness and can be life-threatening and potentially overlooked in the absence of a
confirmed mental health diagnosis.
Destabilizing factors including gender/gender identity, age, employment,
relationship, financial, living situation, chronic medical conditions, chronic pain,

50
substance use, and prevalence of a previous mental health diagnosis could assist in
identifying common and recurrent factors involved in MHAA.
Future research may provide quantitative context to the exact etiology of
substance related MHAA. Prevalence of methamphetamine use and substance induced
psychosis resulting in MHAA could be better tracked. Detailed and current reasons for
apprehension may identify accessibility and treatment gaps.
The research findings support the existence of informal partnerships working in
collaborative and mutually beneficial relationships. Positive research findings may act as
a catalyst in spurring new and expanded stakeholder engagement. Evaluative research of
urban areas with more than one police service may be examined. Future research in this
area may identify successes and areas for growth between competing police services.
Police contact with PMI begins at the police dispatcher level whereas literature
surrounding mental health training largely focuses on the front-line police member (Ritter
et al., 2011). Future research opportunities specific to mental health awareness and
recognition may occur amongst non-front-line police members.
This study may be replicated with more current data, identifying emerging trends
and providing a benchmark for future evaluation of new initiatives. Moreover,
standardized data tracking across existing mental health and police partnerships would
provide a means for program evaluation. Data tracking over an extended timeframe
would facilitate in identification of current and evolving trends.
Future research opportunities may serve to differentiate primary medical reasons
for apprehension comparative to primary psychiatric reasons for apprehension. Should
police respond to a recent or suicide attempt in progress, there may be limited – if any –

51
options for safe and effective stabilization. Overdose ingestion and self-harming attempts
would require medical investigation and intervention not readily accessible in a
community setting. A polypharmacy overdose cannot be mitigated at the residence of a
PMI as medical intervention and testing are required to clarify the extent of any physical
damage.
Child and adolescent psychiatry is pragmatically different than adult psychiatry.
Diagnoses, pharmacotherapies, and community resources differ in comparison to the
adult world. In review of the literature, successes have been identified in the field of
addiction and mental health yet there are no distinct mental health and police
partnerships.
Apart from quantitative research opportunities, qualitatively based studies may
provide an alternate interpretation of successes. The phenomenology of police members
who have worked in mental health and police partnerships may yield useful information
not found in a traditional quantitative approach. Comfort levels of police members
dealing with complex calls for service involving PMI may be explored. The livedexperience of the mental health clinician in a joint partnership may generate new
perspectives on mental health and police collaboration.
Further to qualitative research opportunities the lived experience of the PMI
apprehended by police, working in joint partnerships could be explored. Clarity could be
provided if police members in a mental health partnership are regarded as the same, or
different in comparison to their colleagues working in a patrol capacity.
There is a gap in the literature regarding the evaluation of training. Although
Krameddine et al. (2013) noted a change in behaviors, not attitudes following

52
standardized patient scenario-based training, this research was conducted with EPS patrol
members – not EPS members in a formal mental health and police partnership. Given the
aforementioned lack of change in attitudes, this is an area for further exploration.
Outcomes of mental health training for police members may be multifaceted. The length
of calls for service involving PMI, attitudes toward PMI and healthcare providers, and
stabilization options apart from linkage to community resources or presentations to the
ED could be explored.
5.5

Limitations and Strengths
The major limitation of the analysis included the use of chi-square analysis.

Although a less robust data analysis measure, the chi-square analysis was accurate at both
the 0.05 and 0.001 marks for the first two research questions. A major limitation of
secondary analysis is the researchers analyzing the data are typically not the same people
who are gathering the data (Cheng & Phillips, 2014). Specific to the first research
question, the disposition of 61 out of 2568 people apprehended via a MHAA was
unknown. The unknown disposition portion accounts for less than 3% of all of the
MHAA.
A major limitation of the study is the inclusion of child and adolescent MHAA in
the data. Although US and PACT provide limited direction to police members involved
in child and adolescent calls for service, the mandate of US and PACT is to serve the
adult population. For the duration of 2016, all children and adolescents apprehended in
Edmonton and surrounding area under the Mental Health Act, would be conveyed to the
Stollery Emergency at the University of Alberta Hospital for further assessment. Despite

53
not being brought to the Adult ED, AHS Protective Services members would still capture
MHAA data included in this study.
When PMI are apprehended on a MHAA, they are to be conveyed to a designated
facility per the Mental Health Act of Alberta. Designated facilities are typically hospitals
delegated to provide care for PMI who are apprehended and detained via the Mental
Health Act of Alberta. They are most often found in larger urban settings. The City of
Edmonton is surrounded by smaller communities where policing services are provided by
the RCMP. When PMI are apprehended by the RCMP in rural areas surrounding
Edmonton, they are conveyed to one of the four designated facilities in Edmonton. The
secondary data used in this study does not reflect the presence of, or dispositions of PMI
apprehended by the RCMP and conveyed to one of the four designated facilities in
Edmonton.
The major strength of this research has been the novel approach of analyzing
secondary data within a year-long period. The level of statistical significance is strong.
Despite the data for the first two research question was checked at the .05 level, the data
remains statistically significant at the .001 level, meaning the research findings have an
accuracy of 99.9%. To date there has been no published research on two collaborative
but independent models of mental health and police collaboration within a large urban
setting.
5.6

Knowledge Dissemination Strategy
A Knoxville Model collaborative partnership involves two primary stakeholders:

in the case of this research, AHS and EPS. Equally, the Separate Response Model shares
the same two primary stakeholders. The Knoxville Model (PACT) is a formal and

54
structured partnership between AHS and EPS. The Separate Response Model involves
US assisting EPS, or EPS consulting US on an as needed basis. Positive research
outcomes would be of interest to both an AHS and EPS audience. Cotton and Coleman
(2010) note the Knoxville Model collaborative partnership is the preferred model of law
enforcement and mental health partnership in Canada. The existence of similar
Knoxville Model partnerships in urban settings would enable this research to be shared.
Separate Response Models may be more informal collaborative partnerships, with each
stakeholder identifying a need and a benefit of having a professional relationship with the
other. External validity is strengthened as the research would have the ability to be
generalized to other Canadian urban settings with established Knoxville Model and
Separate Response Models. The research could not be generalized to rural settings.
Urban settings benefit from increased access to addictions and mental health services.
Healthcare and law enforcement collaboration remains a new concept in mental health
care delivery. Post-secondary audiences of Nursing, Psychiatric Nursing, Social Work,
Occupational Therapy, Medicine, Psychology and Police Sciences could be targeted in a
grass-roots approach. Psychiatry Grand Rounds and Nursing Rounds at AHS facilities
would be approached. Patient advocacy groups including the Canadian Mental Health
Association and the Schizophrenia Society of Alberta would undoubtedly voice an
interest in positive research findings resulting in improved care for PMI. Positive
research findings would validate the work done by AHS Urgent and Intensive Services
portfolio. The research would appeal to the broad span of healthcare journals and, law
enforcement and policing journals. The research could be presented at one of the regular
public Edmonton Police Commission meetings. Research findings may encourage

55
further research analysis of secondary data sources. The benefit of accessing secondary
data is to ensure the transformation of data to knowledge. Evidence informed practice
cannot be implemented without first examining evidence informed knowledge.
Chapter 6 - Conclusion
This study explored mental health and police collaboration and its effect on
diverting PMI away from the ED. This study examined the effectiveness of mental
health clinician collaboration with police at the time of crisis. Furthermore, research
findings indicated the presence of a mental health clinician positively affecting both
inpatient rates following a MHAA, and diversion rates from the ED, circumventing the
need for a MHAA. Research findings indicated the informal Separate Response Model
(Urgent Services) as having a greater ability than the formal Knoxville Model (PACT)
partnership in diverting PMI from the ED through safe and effective community
stabilization. Lastly research findings did not indicate any statistical significance in
either inpatient admissions, or discharges from the ED, between substance and nonsubstance related MHAA.
The first research question comprised every MHAA (n = 2479) in the 2016
calendar year brought to one of four local EDs of designated facilities per the Mental
Health Act of Alberta. A high number of PMI diverted from the ED to community-based
resources may indicate a need to further develop existing community resources.
Treatment is not dependent on an inpatient to hospital. Future research opportunities may
include examining the success of community resources in stabilizing PMI.
The second research question comprised every call for service (n = 9078)
involving police with either a formal (PACT) partnership, or an informal (Urgent

56
Services) partnership from April – December 2016. Addiction and mental health related
calls for service involving police may vary greatly in acuity. A call initiated to police
could be assumed to be more acute than a call initiated to a mental health ‘hotline.’ This
could account for the difference in diversion frequency between Urgent Services
involvement and PACT involvement. Further research opportunities may include
examining diversion rates within specific partnerships. Exploring whether an established
clinician-police relationship influences diversion rates from the ED compared to a nonestablished clinician-police member relationship. Qualitative research opportunities exist
to explore the lived experience of both clinician and police members in mental health and
police partnerships.
The third research question comprised every MHAA (n = 984) from August –
December, 2016. Substance use did not have any relation on admission or discharge
rates following MHAA. It would be presumed the etiology behind the symptoms did not
factor into the decision to admit or discharge home. Mental health awareness is an
increasing trend in the media and popular culture. Addictions treatment may be a
polarizing topic, incurring a level of stigma once blatantly directed toward mental illness.
Future research opportunities exist in exploring the prevalence of trauma affecting
substance use within the MHAA population.
EPS patrol, PACT, and US are not identical services. A MHAA is often used as a
last resort, when no options for safe and effective community stabilization are present. It
could be feasible that a lack of safe and effective community resources would result in
increased inpatient admission rates. Regardless this is a gap in service that is not being
tracked in either a sufficient or efficient manner. Positive research findings from the

57
Separate Response Model indicated responding police members were able to collaborate
with mental health clinicians to ensure timely and appropriate care was provided for PMI
in crisis. By virtue of the Separate Response Model being an informal partnership, the
success demonstrated in this study may be indicative of future successes with informal
partnerships. Formal training in addictions and mental health may be beneficial, yet the
findings of this research noted in the absence of formal training, positive results are
attainable by collaboration versus formal education. This assertion is done in absence of
evidence showing what the best practices are for police members involved with PMI.
This is a complex dilemma to which little attention is paid. Police members are not
subject matter experts in addictions and mental health, yet continue to manage complex
calls for service with minimal formal guidance. The ultimate goal of this research is to
facilitate the improvement of care for PMI.

58
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Appendix A

Glossary of Terms
Disposition Checks: For the purposes of this study, disposition checks are completed by
AHS Protective Services members. A disposition check will indicate if PMI are admitted
to hospital or discharged home from the ED following MHAA.
Informal Encounters: Non-criminal encounters between PMI and police not originating
from a call for service.
Knoxville Model: A joint-partnership between a community mental health agency and a
police service involving a mental health professional with a designated police member.
The mental health professional is employed by the community agency whereas the police
member is employed by the police service. The partnership will respond to calls for
service involving mental health concerns.
Mental Health Act Apprehension: An apprehension done by a Peace Officer. See
Appendix A (Form 10).
Separate Response Model: An informal partnership between a community mental
health agency and a police service. Both may attend calls for service at the same time,
but each partner will arrive independently from the other. The Separate Response Model
operates on an as-needed basis.
Substance Related Form 10s: A Mental Health Act Apprehension that is completed
primarily due to illicit drug or alcohol intoxication.

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Appendix B

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Appendix C
Figure 1.1

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Appendix D

Section A
Monthly data gathered (January 2016 – December 2016)
1. Total (n) of Form 10 apprehensions
2. Presentations (n) per one of four hospital sites
3. US/PACT consult (n) of Form 10 apprehensions
4. US/PACT consults (n) admitted following Form 10 apprehension
5. US/PACT consults (n) not admitted following Form 10 apprehension
6. US/PACT consults (n) unknown outcome
7. No US/PACT consults/EPS involvement only (n) Form 10 apprehensions
8. No US/PACT consults/EPS involvement only (n) admitted following Form 10
apprehension
9. No US/PACT consults/EPS involvement only (n) discharged from ED following
Form 10 apprehension
Section B
Monthly data gathered (April 2016 – December 2016)
1. (n) calls to EPS
2. (n) calls to EPS admitted following Form 10 apprehension
3. (n) calls to EPS diverted from ED/no Form 10 apprehension
4. (n) calls to US only
5. (n) calls to US admitted following Form 10 apprehension
6. (n) calls to US diverted from ED/no Form 10 apprehension

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Appendix D
Section C
Monthly data gathered (August 2016 – December 2016)
Same data collection as Section A including the addition of:
1. Substance related (n) Form 10 apprehensions
2. Non-Substance related (n) Form 10 apprehensions
3. Admission to hospital of substance related (n) Form 10 apprehensions
4. Discharge from ED of substance related (n) Form 10 apprehensions
5. Admission to hospital of non-substance related (n) Form 10 apprehensions
6. Discharge from ED of non-substance related (n) Form 10 apprehensions

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Appendix E

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Appendix E

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Appendix E

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Appendix E