Neither police nor clinicians, hospital security represent the potential of enforcement even as they risk their own bodies in the service of medical practice.
The news of George Floyd’s killing set off an anguished public response not only in the United States, but in Canada as well. National news covered the response of our neighbors to the south, but also drew the connection to existing inequities among black Canadians and Indigenous peoples. The recent deaths of Ejaz Choudry, Chantel Moore, and Rodney Levi increased scrutiny on the practice of calling police to perform “wellness checks” of people suffering from mental health crises and further amplified calls to “defund the police.” The Centre for Addiction and Mental Health (CAMH), Canada’s largest psychiatric hospital, joined the call for police to be removed from this role, stating that “mental health is health. This means that people experiencing a mental health crisis need health care.”
This movement is on my mind as a nurse calls the hospital security team to respond to my patient. He is highly agitated and has smashed the drywall, broken the hinges off the door stopper, flipped chairs, and screamed obscenities while describing in detail how he will kill us. The reason why this patient is with us and not in a detention center is that he is experiencing psychosis. We are safe behind specially built windows and locked doors. Staff try to deescalate the situation verbally as security joins us. Given the risk of acute harm to the patient and to others in the emergency room, I order chemical restraints as per protocol, and we agree to first offer some medications by mouth. If the patient refuses, we agree that the next step would be to go “hands on” with security to give an emergency injection in the gluteus; at this point, the patient has been assessed to be too high-risk to leave alone without intervention. Thankfully, he accepts the medications by mouth and is escorted to a seclusion room. We disengage to debrief.1
My experience of emergency mental health practice complicates the view that I have of movements to limit police activity. Individuals like the one I described above offer an image of mental health practice that few of us wish to engage with. Such distressing images are also often invisible to the public. Descriptions of scenes like this can compound stigma, violence, and trauma by the system itself. Many mental health professionals do not speak about how mental health is policed, often demarcating the two as CAMH has done. Health is defined in opposition to policing.
Yet such difficult scenes are not uncommon in a psychiatric hospital—or in general medicine, for that matter. You can walk into a busy general hospital in Canada and find a delirious elderly patient physically and chemically restrained on most nights. Hospital security are almost always involved in these situations. Hospital security’s numerous jobs include running to “code whites” (that is, emergencies involving an “aggressive” individual), escorting distressed patients, and occasionally, holding them down for an injection. The security team performs this role of policing in the hospital and, through their labor, play an ambiguous role: neither police nor clinicians, they are present as the representative potential of enforcement even as they risk their own bodies in the service of medical management.
Hospital security are private actors hired by hospitals. Here in Canada, although they often work in informal partnership with police, they do not carry guns or handcuffs.1 They frequently work alongside nurses and the tools at their disposal include physical restraints, although they do not have the authority to use them without physician orders. They are visible with their distinct uniforms and, nowadays, they wear masks. In the area where I work, they are mostly Caucasian men, with a handful of women and men of color. At this stage of my research, I have not yet been able to establish the details of their salary and benefits; however, I have learned that they often work by contract, with some working overtime and others part-time while they take night courses that may lead to other career goals in the future. Their labor includes the exceedingly mundane, such as being called to open a locked door or provide card access for clinicians. But, during evolving situations like the one I described above, they function as part of the clinical team as an allied frontline essential worker.
I have chosen to highlight hospital security in my research as I have gotten to know a couple of team members in the years I have been a resident. What intrigues me is the way they straddle a line between our ideas of policing and health. Similar to other members of the clinical team, they pull late hours, do their best to settle distressed and delirious patients, and are subject to verbal and physical abuse each day. Interviewing the team members for this essay was tricky, as speaking about their job with me could be risky and there are barriers to approaching management for access, particularly at a time when the intersections of mental health and policing remain under such scrutiny. Moreover, I am aware of the caution I encounter from security team members due to my job as a resident physician, as well as the power dynamics of our patient encounters. However, I have wanted to show how the policing of mental health works in practice (see Strümpell 2017). Where does health begin and policing end? Where, conversely, does health end and policing begin? The demarcation is not always simple. In my observations, the security team play a variety of roles, oscillating between providing safety for staff and patients, exerting force in the service of mental health, and responding to clinicians’ calculations of diagnosis and risk. Their labor and ability to navigate the bureaucratic medical hierarchy reveal the governing language and complicated practice of clinical mental health practice.
There are several ways to call upon the services of the security team in the acute mental health setting. In this setting, the language of “risk” and of “harm” to self or others is ever present. These terms form part of the clinical staff’s framework of meaning and justify monitoring or intervention through medication or psychotherapy. Security services are sometimes at the periphery of these engagements, often remaining on standby if clinical staff are concerned about harm to themselves or self-harm by the patient. We move in complex working relationships that utilize this language of risk and harm based on perceived behavior by the patient, which is dynamic but can reach a tipping point at which a scene is judged to be of risk. When this occurs and the scene cannot be deescalated or managed by the clinical staff alone, we call on the security team, symbols of policing authority, in order to emphasize the options of medications, restraints, or seclusion to the patient. As Jeffrey Martin (2016: 473) notes, we place the “ideological visage” of police work, with hospital security playing the part, in between the patient and ourselves. In doing so, there is a moment when the dichotomy of health and policing is reified, as the security team goes “hands on” and the patient struggles. Interestingly, the application of any chemical restraint is actually enacted by the nurse, a form of violence in the service of powerful neurophysiological interventions that can be both tranquilizing and, at times, healing.
I also want to provide a contrasting example, when hospital security have represented comfort and safety. There are often cases where security team members engage patients as well or better than clinical staff. Perhaps, to the patient, there is a different sense of a nonmedicalized encounter with neither clinical staff nor police, but another social category. I recall a young male patient who was handcuffed and had been brought in by police. He was cursing the police and dismissing our mental health assessments as irrelevant, but he would speak to our security team member. Was this a recognition of the team member as a source of safety, in contrast to the police? Or was it the fact that the team member was not there to carry out clinical tasks, asking questions to assess psychosis, substance use, or the details of his mood? Or was it simply because the young man knew he could not leave the hospital until he had been evaluated and so talking to security was his best option to pass the time? Regardless of the reason, this team member was able to get the patient a sandwich and gently encourage him to speak to me while exchanging jokes and casual talk. The specter of violence remained insofar as this team member was obliged to make sure that the patient did not escape, but in his peripheral role he managed to engage the young man beyond policing and beyond medicalization.
Recently, I asked a different security team member what his hospital work and embeddedness with the mental health team was like for him. I could see him thinking about how to respond to a psychiatry resident who was asking about our working relationship. His answer reverted to the binary of policing and health: “We listen to you as the mental health experts. We trust that you’re the experts and know what needs to be done.”3 Yet I know that he is also an expert in navigating his multiple roles, often providing support or a gentle voice in a way that challenges representations of violence and policing. However, I do not challenge him on this distribution of expertise; there are patients to see and documents to sign. My work is that of a resident physician and I hear a sudden, loud banging on one of the doors. The nurses check the camera and we see a patient escalating, kicking at the locked exit. I provide the medical vocabulary that underpins the violence work I, too, perform. We call for backup, the security team puts on gloves, I order sedation, and we both get to work.
1. To protect anonymity and confidentiality, details of the vignettes have been amalgamated and adjusted.
2. In the hospital, police no longer have legal jurisdiction and the enforcement role falls to security teams. That said, the frontline enactment of enforcement work is sometimes mixed, as when a patient suddenly trying to flee requires both police and the security team to collaborate while still on hospital grounds. Such nuances are not within the scope of this essay.
3. Chemical restraints commonly include benzodiazepines and the class of drugs known as antipsychotics. Based on a diagnosis and clinical indications, these chemical restraints can function as sedatives or tranquilizers in order to get a patient to sleep or relax. At other times, they can function as therapeutic agents or are even potentially life-saving, actually targeting symptoms such as psychosis or catatonia that cause agitation or distress.
Sang Ik Song is a psychiatry resident at McMaster University. He studied history and medical anthropology as an undergraduate and is currently pursuing graduate studies in Health Research Methodology. He plans to research difficult intersections of mental health with law and culture.
Photo by Chris Henry.
Martin, Jeffrey. 2016. “Calling the Police, More or Less Democratically.” Theoretical Criminology 20(4): 462–81.
Strümpell, Christian. 2017. “The Anthropology of Work and Labour: Editorial Note.” Ethnoscripts 19(2): 5–14.