Tragedy spawns change. In 1987, the Memphis, TN Policeresponded to a crisis call involving a man reported to be mentally ill. He wasarmed with a knife and cutting himself. After a brief standoff and somethreatening actions on the part of the subject, he was shot and killed.
The local chapter of the National Alliance for the MentallyIll (NAMI) voiced that the police were untrained and unprepared to respond to acrisis involving mentally ill subjects. The mayor of Memphis formed a taskforce to research the various models for dealing with such a situation. Theresult was the specially trained Crisis Intervention Team (CIT).
This is a patrol-oriented, 40-hour training course based onthe premise that special people have special needs, will respond in apredictable way, and deserve special care. The somewhat surprising aspect ofthis apparently touchy-feely approach is that fewer people go to jail, fewerpeople go to mental hospitals, fewer officers and subjects are injured, thereare fewer repeat arrests, fewer people prosecuted (or otherwise enter thejudicial system) and more people are identified to get the appropriate mentalhealth care.
CIT should be required training for all SWAT negotiators.However, CIT is also geared for all officers who respond to attempted suicidecalls and other calls that may involve the mentally ill. CIT officers aretaught to recognize the various psychiatric syndromes, the biologic basis forsevere mental illness, de-escalation of crisis situations, the law pertainingto the detention of the mentally ill, and access to emergency and non-emergencymental health services.
The first day of CIT training begins with the many myths andmisconceptions of severe mental illness. For law enforcement, the biggest mythinvolves the tendency of the severe mentally ill to become violent. That simplyis not true. Bizzare behavior? Yes. Harmful to self? Possible. Violent toresponding officers? No.
The severely mentally ill need an entirely differentapproach. It calls for an entirely different voice tone, voice volume, personalspace, and both observational and questioning skills. Is this just anotherdrunk? Or is there something else here? The emphasis is on tolerance, patienceand understanding.
Bi-polar, or manic-depressive illness, involves changes inthe PROPORTION of normal emotions. About 2% of the population has bi-polarillness, making it one of the most common forms of mental illness.
Normal is happy. Manic is exaggerated euphoria and poorjudgement. Normal is glum. Depressive is persistent and extreme helplessnessand hopelessness. Bi-polar illness is often complicated by alcohol or othersubstance abuse. Psychotic symptoms include hallucinations (seeing, hearing,smelling or otherwise sensing things that do not exist) and delusions (falsebeliefs and thoughts that are illogical and incorrect, held despite evidence tothe contrary).
A person suffering from bi-polar has mood swings from highand irritable to sad and hopeless. The cycles vary greatly in both duration andfrequency. The manic phase gets shorter and the depressive phase gets longer.Left medically untreated, 20% of bi-polar victims commit suicide. Almost allpeople with bi-polar can be helped with treatment to stabilize the severe moodswings.
Those with schizophrenia suffer from problems withPERCEPTION of the world. These people have faulty perceptions of reality. Theysee, smell, feel and hear things differently than they really are. Theschizophrenic is plagued by realistic and vivid hallucinations and bydelusions, of which they are firmly convinced. These people have an emotionalreaction to what they see, hear, smell, feel or believe. They may act on theseemotions. They cannot be talked out of their perceptions. It is as real as ourperceptions are to us.
These people will pay more attention to the voices in theirhead than to your spoken voice commands. They are much more familiar to voicesthan to talk. In fact, some victims miss the voices that the meds prevent fromrecurring. Some voices carry on a normal conversation, some chastise, humiliateor harass the person, and some are commands to do dangerous acts.
Delusional thoughts include paranoid beliefs of persecution,or that they are being cheated, poisoned or conspired against, or that they area famous or an infamous person, including both good and evil religious figures.
About 1% of the population has schizophrenia, the mostdistressing and disabling of all the severe mental illnesses. The meds forschizophrenia are less effective than those for bi-polar and major depression,and the side effects are greater. In the best cases, with the newer drugs,relapses into psychotic episodes are “reduced” in intensity and frequency, asopposed to being prevented.
Major, or clinical, depression is the real thing. Everyonefeels sad, down or blue. However, such feelings pass quickly. Major depressionis not a passing mood. It is a mental illness that is persistent and caninterfere significantly with the person’s ability to function.
About 5% of the general population has major, or clinical,depression. It is the persistence and severity of the emotions that distinguishthe severe mental illness of major depression from normal mood changes. Majordepression is severe enough to require treatment.
The significant symptoms of major depression are feelings ofworthlessness, hopelessness, helplessness and guilt. They have no energy andhave either great trouble sleeping or sleep too much. Most significantly, thesepeople have repeated thoughts of death and suicide.
While many factors can contribute to major depression, thereis no single cause. Of course, stressful events can trigger this, such as lossof a family member or a friend, divorce, custody battles, financial difficultiesof all types, chronic medical illness and problems with personal relationships.This is one of the most treatable of all the severe mental illnesses. Up to 90%of all depressed people respond to medication and therapy.
Detention and Commitment
The laws associated with mental illness differ by state.Each CIT course will cover the laws that apply to that jurisdiction. Generally,most states will have a number of levels, each increasing in the number ofpeople who must approve of the detention or commitment action.
An Immediate Detention Order is probably going to be ashort-term stay (24 hours), which any officer can sign. An Emergency DetentionOrder will probably be a slightly longer stay (72 hours), and need the approvalof a judge and a doctor. A Temporary Commitment will be a much longer stay (upto 90 days) and involves a formal court hearing. A Regular Commitment involvesstays for up to one year.
While the reasons for the detention or committal may vary bystate, expect to hear a two-pronged approach. First, the person must besuffering from a mental illness, an articulatable and diagnosable mentalillness. Second, they either must be dangerous to themselves or others, or theymust be gravely disabled to the extent that they are unable to protect themselvesfrom harm, including unable to sustain themselves.
The judge, and intake staffers at mental hospitals, willwant to know, “What happens if we don’t put him in detention?” They will alsowant to know 1) who called the police, 2) why you were called, 3) what youobserved when you arrived, 4) what your concerns were, and 5) what meds theperson is on.
Specifically, what is the immediate concern? What is therisk of violence? What are their unresolved, untreated symptoms? What is theiraccess to weapons? What is their violence history? The biggest predictor ofviolence is a history of violence.
Not all CIT courses will have visits to institutions andextensive interviews with the seriously mentally ill…but they should. Most ofthe second day was spent visiting the public and private mental healthfacilities in the area. This included the hard, lock-down hospitals forpotentially violent persons under involuntary, court-ordered commitment. Italso included visits to day shelters and to facilities that teach both socialskills and job skills to the severely mentally ill.
Everyone we met volunteered to see us and knew that we werepolice officers. In some ironic twists, some of these people ended up meetingone of their previous arresting officers. They talked about the specifics oftheir mental illness, the effect it had on their lives, and the meds they wereon. They talked about good encounters with police, and the bad ones, how theapproach may have gone better. And they answered every question…even the hardand awkward ones.
The patrol lesson here is to expect extremely long periodsof time to answer even simple questions or follow even simple voice commands.Now, this is a potential problem when the question is: “What is your name?” Andeven more of a problem when the command is: “Show me your hands.” Without onehint of hostility or resistance compliance may take 30 seconds…or longer!Animated hand movements may not be signs of aggression.
Day 2 ended with what would be increasingly complicated,confusing and complex role play scenarios. Each was based on actual, localcalls for service. The lessons learned were many. Slow approach. Neutral handand body position. Even and level voice and tone. Helpful attitude. Moreemphasis on inquisitiveness than authority. Answer legit questions but keepthem focused on the reason for the call. Assure their safety. Ask about theirmeds. Don’t make promises you can’t keep.
Day 3 began with a detailed How-To for assessing theseriousness of suicide talk. Among mental health professionals, it is a threatthat deserves additional questioning, and that is it. It is not necessarily ared alert, nor does it mandate hospitalization. In fact, the “S” word is nowrecognized as the ultimate weapon of emotional manipulation. The CIT officercan reasonably assess how serious the person is about suicide in less than fiveminutes.
Suicide is serious. It is the 11th leading cause of death inAmerica. Half of the people admitted to community mental health facilitieseither talk of, or have attempted suicide. However, it is also an area withlots of talk and not much action.
The stigma of suicide is no longer shameful. People willmake the claim to avoid going to jail, to try to win back a boyfriend, to getinto a shelter, or to get a little attention or sympathy. The intent is for theCIT officer to screen out the ones who are not even close to serious…and bringinto the mental health system those who are.
Ask them directly. Are you considering killing yourself? Areyou considering suicide? Listen for either a passive or an active answer.Passive is: “I don’t want to go on anymore.” Active is: “I am going to use thatgun.” Even if the answer is an active one, ask about their plan. How specificand detailed is it? “I am going to buy a gun” is a lot less serious than “I amgoing to take the shotgun out of the closet and load it with ammo from thenightstand drawer.”
Ask how long they have had these thoughts. Have they dwelledon this a lot, or is this a fleeting thought? Ask if the person has the meansto do it. Do they have the pills? Or know where to get them? Or know what kindto get? Have they taken any steps to actually get the pills?
Ask if they have ever attempted this before. A person whohas specific plans and has made a serious attempt before is more of a concernthan one who has done neither. People who have made more than one attempt areat a higher risk than those who have made none or only one attempt. What wasthe nature of these attempts? Threats or attempts in front of other peopleespecially during or after arguments are less serious than those made in secretand discovered by accident.
Have they done any special preparation? Updated a will? Sentgoodbye letters? Given away important possessions? Called long-lostacquaintances out of the clear blue? Got things otherwise in order, planningnot to be around?
Depression is only part of what drives people to suicide.The real key is desperate misery that makes life so unbearable that death lookslike a relief. Depression plus anxiety is dangerous. Psychotic plus delusionalis dangerous. And so are alcoholics, because they can be impulsive and withoutinhibition. Those with access to guns are more dangerous than those with accessto pills.
Most of the rest of the day was spent in role play usingtwo-officer teams. Halfway through the training, everything got a bit tougher.Those in the roles of the severely mentally ill were closer and closer to reallife. And the evaluators were pickier and pickier about the smallest things.
Use their actual name, not sir. Get them to focus on thereason for the call. Emphasize their safety. Explain the problem. Work onrapport. Avoid asking them “why” they are doing anything. Watch fingerpointing. Don’t join the hallucination. Don’t join the delusion. Don’t discussor argue politics. Don’t discuss or argue religion. Don’t try using logic.Present to them the reality of why you were called. Explain why you are here.Explain what you want done. Ask questions.
Day 4 began with a detailed explanation of the medicationsused to treat severe mental illness. The top priority question in your mindshould be: What medicine are you on? Followed up by, What is that supposed todo for you? A professor of nursing at a major university presented a long anddetailed list of psychiatric meds and what illnesses they were used for and theeffects of overdoses. For example, Risperdal (risperdone) is used forschizophrenia and bi-polar disorder. Effexor (venlafaxine) is used for majordepression. Xanax (alprazolam) is used for anxiety and panic disorders. Atleast 40 such drugs exist.
Next on the agenda were long and complicated role playscenarios, which took most of the day. For these scenarios, the intake staffersat both the local hospital and the community mental health center were at theirdesks waiting for the officers to call. Are we going to clear the scene? Callfor family or friends? Transport to medical or mental facility? And would theyaccept the person? Transport to jail? So many choices. So many judges watchingevery action and listening to every word.
Yes-no questions don’t help much. Why questions always gothe wrong direction. Tell me what meds you are on. Who is your doctor? Tellthem the reality from your perspective. Don’t argue about reality from theirperspective. Tell me how we can help. Keep them on track. Slow down in yourspeech because they are already confused, or racing in their thoughts. When didyou last eat? When did you last sleep?
The last day began with a training block on adolescents andmental illness. The theme of the session was that mental illness is never anexcuse for bad behavior…but it may be a reason. There are no excuses forcriminal behavior.
In teens, all emotions are exaggerated two-fold. Everythingis extreme, in both the positive and the negative. Adolescents think only ofthe here and now (no consequences for their actions). And their entire modusoperandi is that they resent the power and the authority that both officers andparents have.
Of course, it seems half the kids in America have attentiondeficit disorder, more correctly known as Attention Deficit HyperactivityDisorder (AD/HD). The problem is that AD/HD and bi-polar mimic one another,i.e., some of the AD/HD kids are really bi-polar. This misdiagnosis is common!
It is important that accountability be retained. You can’tsay, you have this problem, here are the meds, and it’s not your fault. Thereal problem is that you are a little punk, totally disobedient, and just plainbad. Meds are no substitute for poor parenting skills.
The real solution is a combination of both treatment ANDconsequences. Consequences is a code word for punishment. Nurture anddiscipline…treatment and consequences. By the time the adolescent has a run-inwith law enforcement, the soft corrections have probably already been tried. Itis now time for a slap of reality, a hard line, an emphasis that there aredefinite consequences for poor behavior.
This punishment should be predictable, logical, and itshould have an impact. The solution is a combination of treatment (talk andmeds) and punishment. However, the effects of punishment are temporary andpunishment is not the goal…changing behavior is. This will require parentingfrom the parents.
A few general rules help for dealing with these adolescents.Give clear commands, and then give them time to comply. Don’t argue with them,and don’t try to convince them of anything, because they think they knoweverything. Give them time to cool down. Just like adults, they need to saveface, so give them these kinds of options.