What are the various steps leading to application of the ARPP?
In the majority of cases, the process begins with a domestic crisis situation. For example: shouting, a gesture, a threat, etc. Witnesses, whether relatives or friends, generally contact the Kativik Regional Police Force (KRPF) at 819-XXX-9111.
- the police officers go to the premises to ensure the safety of the persons involved;
- the police officers contact social services to proceed with crisis intervention on the premises where the individual in crisis is located;
- social services meet with the individual and his entourage to:
- defuse the crisis;
- obtain the individual’s consent;
- estimate the dangerousness linked to his mental state;
- establish a safety net with the individual and his entourage, if he consents.
- During this time, the police officers remain on site to ensure the safety of all.
- if all the criteria are met (serious and imminent danger + absence of consent), social services may request that the individual be brought by force to the CLSC or the community’s health centre (application of section 8 of the ARPP);
- upon arrival at the CLSC or health centre, the nurse on duty admits the individual and the team (police officers and social services) and performs a summary assessment of the individual’s physical state, if he consents;
- the nurse, the intervener of social services and the police officers then quickly exchange information on the crisis situation and contact the physician on duty to inform him of the situation. Only a physician is authorized to initiate preventive confinement;
- no psychiatric examination or court authorization necessary to initiate preventive confinement, which shall be of maximum duration of 72 hours;
- if the physician deems that the criteria to initiate preventive confinement are not met, the individual must be released immediately and with no further formality.
How were these steps defined?
Several laws and protocols govern this intervention:
- Act respecting the protection of persons whose mental state presents a danger to themselves or to others;
- section 8 of the ARHSSS;
- sections 26 to 31 of the Civil Code of Québec;
- various practical guides of the MSSS;
- various protocols of the health centres (protocol on institutional confinement, protocol on control measures, UTHC protocol for intervention in crisis situations, etc.);
- regional training on the best practices in suicide crises in Nunavik;
- and many others.
In 2018, section 118.2 was added to the ARHSSS. That section obliges all health and social services institutions of Québec with the installations required to proceed with institutional confinement (section 6 of the ARPP) to:
- adopt a protocol on institutional confinement;
- circulate that protocol among the employees, partners, users and their close relatives, and the general public;
- offer training and support to the employees on application of the protocol;
- report to the board of directors on the cases of institutional confinement at their installations.
To support the province’s institutions, the MSSS published two documents aimed at establishing ministerial standards (best clinical practices) for institutional confinement and providing a protocol template for the institutions.
In April 2019, the boards of directors of the IHC and the UTHC adopted a protocol on confinement. Since July 2019, the employees have been trained and supported. The present tool aims to inform all the persons concerned about the statute and the protocols. Work is under way toward creation of a memorandum of understanding for cross-sector cooperation that will include the KRPF and the legal system (judicial district of Abitibi-Témiscamingue and Nord-du-Québec).
Concurrently, all social-services interveners of the Nunavik region receive training on the best practices in suicide crises in Nunavik. That training is a regional and cultural adaptation of the provincial training bearing the same title. It has been offered in Nunavik since 2016-2017. It takes four days and is also offered to all other front-line interveners in Nunavik, for example, those at Isuarsivik and Kativik Ilisarniliriniq. It has been obligatory since 2019. Its objective is to develop best intervention practices among interveners, fostering the search for alternatives in terms of intervention and exceptional recourse to the ARPP.
The UTHC adopted a protocol specifically for section 8 of the ARPP. That protocol covers on-site crisis intervention (mandate of social services) and the estimation of dangerousness linked to mental state. Training is offered to all employees of social services and youth protection, thus ensuring the capacity to intervene in crisis intervention on site.
The IHC and the UTHC also established protocols concerning control measures. Control measures are additional means that can be taken to ensure individuals’ safety and physical integrity, whether confined at an institution or not, for example, physical or chemical restraint. Thus, institutional confinement and control measures are two different things that can be used in conjunction, but only when necessary.
Some important definitions:
Restraint: control measure consisting of preventing or limiting an individual’s freedom of movement through human force, mechanical means or privation of a means he uses to compensate for a handicap
Isolation: control measure consisting of confining an individual to a place for a determined length of time and which he cannot leave freely
Chemical restraint: control measure consisting of limiting an individual’s capacity for action through administration of medication