Law Enforcement and the Mentally Ill (3)

8/10/2019 Law Enforcement and the Mentally Ill (3)

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ROCIC Special Research ReportBy Publications Specialist Jennifer Adkins

2013 Regional Organized Crime Information Center

Introduction ..........................................................................2

Describing the Problem ......................................................2

Impact on Police Resources .............................................4

Effective Response Strategies ..........................................7

Managing Risks ...................................................................9

Common Situations ..........................................................11

Psychotic Disorders .........................................................12

Mood Disorders .................................................................14

Anxiety Disorders ..............................................................15

Related Problems ..............................................................17

Police Homeless Outreach Programs ............................19

Altered Mental Status from Medical Illnesses ...............21

Conclusion .........................................................................23

Sources of Information .....................................................24

ROCIC - A RISS Center www.riss.net

A Proven Resource For Law Enforcement

Law Enforcementand the Mentally Ill

Effective Policing Techniquesfor Persons in Crisis


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ROCIC Special Research Report Law Enforcement and the Mentally Ill

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P roblems associated with people with mental illnesspose a signi cant challenge for modern policing.Given the false stereotype that all mentally disorderedpeople are dangerous, ci zens o en call upon the policeto do something in situa ons involving mentally illindividuals, par cularly when they exhibit the morefrightening and disturbing signs of a mental disorder.

Police o cers are not mental health experts, butthey are o en the rst on the scene to deal with thementally ill, such as those with psycho c disorders,mood disorders, and anxiety disorders. It is importantto recognize at the outset that mental illness is not, inand of itself, a police problem. However, a number ofthe issues associated with people with mental illnesso en do become police ma ers. These include crimes,suicides, disorder, and a variety of calls for service.

As with all law enforcement decisions, the respondingo cer must exercise discre on in choosing the mostappropriate ac on when encountering a personexhibi ng signs of mental illness or altered mentalstatus. The more knowledge and training that theo cer receives, the more it will impact this response,and heighten o cer safety and the safety of the subject.

Describing the ProblemPolice involvement with mentally ill persons is basedon two principles of common law: (1) The power andresponsibility of the police to protect the safety andwelfare of the public, and (2) The protec on of thedisabled, such as mentally ill persons.

Safety is the primary concern both safety for theo cer and for the (person in crisis), said Lieutenant JonGarlick, Mental Health O cer with the Calhoun County,Ala. Sheri s O ce. People in crisis are emo onal, andreason takes a back door. The goal in any contact is toreduce the emo onal level and therefore reduce thedanger.

Approximately 22 percent of U.S. residents have aserious mental illness. An es mated 7 percent of policecontacts in jurisdic ons with 100,000 or more peopleinvolve the mentally ill.

Mental illness is a signi cant factor in the injury ordeath of on-duty law enforcement o cers. Earlystudies (1998-2001) found that people with mental

De nition of Mental Disorders

Diagnostic and Statistical Manualof Mental Disorders (DSM-IV)

A clinically signi cant behavioral orpsychological syndrome or pattern

that occurs in an individual and thatis associated with present distress(i.e., a painful symptom) or disabil-ity (i.e., an impairment in one ormore important areas of function-ing) or with a signi cantly increasedrisk of suffering death, pain, disabil -ity, or an important loss of freedom.The syndrome or pattern must notbe merely an expectable and cul-turally sanctioned response to aparticular event. It must currentlybe considered a manifestation ofa behavioral, psychological, or bio -logical dysfunction in the individual.No de nition adequately speci esprecise boundaries for the conceptof mental disorder. Also known asmental health, mental impairment,mental illness, brain illness, and se-rious brain disorder.

Source: The Liberty Crier


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illnesses killed o cers at arate ve mes greater thanthe rest of the popula on. Andthe mentally ill popula oncon nues to grow.

Encounters with police are

also dangerous for mentallyill persons. It is es matedthat people with mentalillnesses are killed by police in

jus able homicides at a ratenearly four mes greater thanthe general public. State andlocal sta s cs are inconsistent,but it is es mated that 375 to500 people shot and killed bypolice each year in this country

have mental health problems.

Police o cers are frequentlynot amenable to being told theres a be er way of doing things than whattheyre doing, said Ron Honberg, the Na onal Director for Policy and LegalA airs at the Na onal Alliance on Mental Illness, in a news account. Its anentrenched culture that doesnt change easily.

There are also many cases where individuals with mental illnesses provokepolice into killing them, commonly known as suicide by cop. In some cases,the o cers knew the subjects were disturbed but lacked the training and

resources that might have prevented them from taking lethal ac on. Of typicalsitua ons involving mentally ill persons, o cers have rated the threat of suicideas the most di cult to handle. Reduc on of injuries and deaths of persons withmental illness should be a high-priority objec ve for police agencies.

Factors Contributing to the ProblemDe-ins tu onaliza on: A er 1960, societys preference shi ed away fromins tu onalizing people with mental illness. Mental health prac ces werechanged, and many hospitals were closed. However, community-based serviceswere not adequately developed to ll the void in treatment. For instance, as of

2011, only 10 percent of the na ons approximately 15,000 police departmentso ered crisis interven on programs.

Criminaliza on: A er de-ins tu onaliza on, calls to police about crimes anddisorder involving people with mental illness increased. Because of an apparentlack of choices, police turned to arrest as the only available solu on to theimmediate problem. This had the e ect of criminalizing mental illness and re-ins tu onalizing people with mental illness. An es mated 10 to 15 percent of

jailed people have severe mental illnesses.


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Medicaliza on: An important aspectof community-based mental healthcare is ge ng non-ins tu onalizedpeople with mental illness to taketheir medica on as prescribed.Factors interfering with the regularuse of prescribed medica ons includenega ve side-e ects associated withsome drugs, the high cost of medica on,the tendency to self-medicate, theabuse of illegal drugs and alcohol, andthe lack of follow-up by the mentalhealth system.

Priva za on: Many mental healthfacili es are operated by privatepar es. Privately run facili es havean inherent incen ve to cut expenses,o en resul ng in minimum and low-paid sta . This results in a facility that

relies on police to help manage pa ents/clients. As a result, police resourcesare wasted and people with mental illness do not get the quality of care thatthey deserve.

Impact on Police ResourcesLaw enforcement o cers are the rst responders to people with mentalillnesses who are in crisis. These encounters have increased as the number ofmentally ill persons in the general popula on, in jail, and among the homelesshas grown.

Law enforcement has always confronted more mentally ill people in crisis thanany other profession, stated Lt. Garlick. Typically, law enforcement o cersare not mental health professionals and the training they receive is minimalcompared to other professions. An encounter with an EDP (emo onallydisturbed person) will take longer and o en requires more o cers than non-EDPs.

O cers who encounter an EDP crea ng a disturbance have three choices:

1. Transport that person to a mental hospital2. Arrest the person3. Resolve the ma er informally

Studies found that police resolved situa ons informally in 72 percent of thecases, made an arrest in 16 percent of the cases, and ini ated emergencyhospitaliza on in 13 percent of the cases.

Most state laws permit o cers to take these individuals into custody andtransport them to hospitals if they meet the legal criteria for psychiatric


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evalua on. However, transporta on and hospital security demands associatedwith mentally ill persons are perceived as a major consumer of law enforcementresources na onally; increasing amount of me and manpower.

In addi on, police use of hospitals is limited by the number of psychiatricbeds available in the community and by the criteria for admission. Personscategorized as dangerous may not be admi ed to some hospitals, nor may

persons with pending criminal charges.

The trend has been to reduce bed space for the mentally ill throughout thecountry, said Lt. Garlick. We are at the lowest per capita for mental healthbeds since 1880. This forces people back to the community for outpa enttreatment.

In Alabama, we have approximately 100,000 people being treated by communitymental-health centers. Approximately 1 percent of those require some form ofpermanent hospitaliza on. These 1,000 people circle through the system fromhospital commitment to outpa ent treatment un l they either experience

decompensa on that results in an ER visit or a crisis that lands them in jail.If the person is considered too dangerous (or in some cases their behavior is notconsidered severe enough) to qualify for hospital admi ance, arrest is the onlyalterna ve for o cers. The person exhibi ng signs of mental illness may bearrested when considered deviant, disorderly, and it is thought that the personwould con nue to cause a problem if ac on was not taken.

Unfortunately, the criminal jus ce system is not designed to be a major point ofentry into the mental health system. An arrest labels the person as a criminaland will most likely result in future arrests due to disorderliness. The arrest

rates for persons exhibi ng signs of mental illness are greater than that of other


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ci zens involved in similar typesof incidents. And the arrest ratecon nues to grow for mentally illpersons.

In jail, the impact is greater.Jails are not hospitals and dont

have the resources available formedica ons or therapy or evensuitable bed space, Lt. Garlicksaid.

In general, police make a formaldisposi on hospitaliza on orarrest when the situa on, ifunchecked, would escalate andrequire further police assistance.

Informal op ons are based onhow the person is perceived. Disturbed people who are likely to behandled by informal means are o en categorized as neighborhoodcharacters, troublemakers, and quiet, unobtrusive mentals. O cersfamiliarity with these types enables them to soothe them withouttaking more formal ac on.

Police know the parameters of the behavior of their neighborhoodcharacters, such as Batman or Mailbox Molly. O cers familiaritywith their idiosyncrasies and symptoms enable them to placate them.

Troublemakers are not usually hospitalized or arrested. Interven onin such cases may not be worth the trouble. These persons may havesuch a long history of disturbance that o cers nd it a hassle tocon nue to arrest him or her.

Quiet, unobtrusive mentals, o end neither the popula on nor thepolice with obvious manifesta ons of their illness, and their symptomsare not considered serious enough to warrant hospitaliza on.

The police problem of people with mental illness is closely connectedto three other problems: homelessness, drug abuse, and alcoholabuse. Addressing people with mental illness in your jurisdic onmay require that you take on these problems as well. This guide willaddress these di cul es associated with the mentally ill popula on.

In general, a smallsubset of people

with mental illness,those who are

actively experiencingserious psychotic

symptoms, are moreviolent than the

general population.Violent and criminalacts that are directlyattributable to mentalillness accounts fora small proportionof all such acts inthe United States.The vast majorityof persons with

mental illness are

not criminals, and ofthose who are, most

are not violent.

Threat of

Violence


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Recommendations for an Effective Response StrategyThe public mental health system and the criminal jus ce system mustcollaborate so that police o cers have several alterna ves, other than arrestor hospitaliza on, when handling mentally ill persons in the community. Policeo cers must also receive adequate training in recognizing and handlingmentally ill ci zens so that individuals who are more disordered than disorderlyare referred to the appropriate system.

1. Working with the mental health community. Give careful considera onto who else in your community shares responsibility for the problem andcan help your department be er respond to it. Mental health professionalsand advocates for mental-health-system reform can be viable partners withpolice o cers. Be the leader in helping these organiza ons collaborate andshare informa on.

2. Working with emergency hospitals. Nego ate no-refusal agreements withhospitals. Several jurisdic ons, including Memphis, Tenn., have establishedcrisis response sites where police can transport people in mental health

crisis as an alterna ve to an emergency room or jail. These sites are usuallylocated in hospitals as a drop-o point and have a no-refusal policy withpolice. These agreements establish a successful liaison between the policedepartment and the mental health system. At the least, police agenciesshould meet with sta of local hospitals periodically to develop protocolsand address problems. For example, it should be clear how long an o cermust remain at the hospital and when security can take over. It should beclear whether the police or an ambulance is responsible for transpor ng apa ent to another facility.

3. Training police o cers. O cers should receive training about mental

disabili es and their symptoms, available community resources, and basiccrisis communica on skills. Proper training typically integrates lecture,discussion, tours of mental health facili es, and role-playing that doesnot exaggerate the danger involved in police encounters with people withmental illness. The most popular response to incidents involving personswith mental illness has been deploying specialized police o cers who aregiven extra training. Agencies could also deploy a specialized non-policeresponder, such as a social worker or mental health clinician. Models ofthis type have been successful in Birmingham, Ala. and Knoxville, Tenn.

Sergeant Keith Simonds with the Oklahoma City, Okla. P.D. teaches a

ve-day crisis interven on course. On the rst day of class, Sgt. Simondsstrikes a typical police o cer pose: feet planted rmly, hand on gun.

Doesnt exactly say, Im here to help you, does it? Sgt. Simonds said ina news account. More like, Im here for target prac ce. Sgt. Simondsexplains that when a crisis interven on o cer encounters someone inpsychiatric crisis, he should approach with cau on and pa ent talk: Howare you doing today, sir? Looks like maybe youre having a bad day. Are youtaking any medica on?

Watch for

opportunities toattend specializedROCIC Training

events at

www.rocic.com.


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4. Informing patrol o cers. Agencies should provide twotypes of informa on to patrol o cers: (1) informa onabout clinics, shelters, and mental health servicesavailable in the community, and (2) informa on oncommunity members with a history of mental illnessand repeat o enses. Patrol o cers must also havealterna ves to deadly force, including pepper spray and

stun guns.5. Targe ng chronic disturbers and repeat calls for service.

If a person is merely being loud, annoying, or ac ngstrangely, involuntary commitment is not usually an op on.In response, o cers may a empt to soothe the vic m,look for a guardian, command the person to leave or cease,or make an arrest for disorderly conduct. If the personengages in the same behavior repeatedly, police may runout of op ons quickly and may have to empower thecommunity to apply more supervision over the disturber.

Theres a lot of individuals standing on a street cornerwho may be cursing and may be yelling and may begoing in and out of tra c, said Major Sam Cochran, thecrisis interven on program coordinator for Memphis,Tenn. P.D., in a news account. Each of those wouldbe an infrac on disorderly conduct, disturbing thepeace, or something of that nature. But who reallycares if the individual goes into the criminal jus cesystem? The public wants that person o the street.

In addi on to chronic disturbances, some individualsmay call police repeatedly for police service. This mightinvolve a large number of false, imaginary, or trivialcalls. If police can iden fy the caller, they can takefurther ac on, such as seeking assistance from socialworkers or mental health professionals. In Ithaca, N.Y.,calls from emo onally disturbed people were the policedepartments most common non-crime calls. A newsystem was adopted in which calls from or about peoplewith mental illness were handled as they were received,but also referred to community-based o cers and

mental health providers for next-day follow-up. Chroniccalls were all but eliminated.

6. Targe ng hot spots. Crime, disorder, and calls for servicerela ng to mentally ill persons tend to be concentratedin a subset of loca ons in any jurisdic on. Once hot spotsare iden ed, it is important to analyze the situa onto determine the nature of the calls and why they areoccurring, before tailoring a response.

Of cer James Smith takes a break from patrollingthe streets of Memphis, Tenn. to check on Joseph,

a man he has dealt with in the past. Team membersoften establish a rapport with some of the mentally ill

people in their precincts. Members of the Memphis police crisis intervention team get 40 hours of

training on mental health and con ict resolution, thenregularly handle calls involving disturbed people.

They work closely with a hospital that accepts peoplefor psychiatric assessments around the clock. In

Memphis, fewer than 1 percent of calls handled bythe police crisis intervention team result in arrest,

compared with an estimated national average of 20 percent on similar calls. Source: hamptonroads.com.


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Managing RisksInnova ve programs designed tomanage the risk of encounterswith people with untreated mentalillnesses have been implementedin some communi es, and free uplaw enforcement me, money, andother valuable resources.

Law enforcement agencies canbe proac ve by working with theprobate court to create a mentalhealth o cer who can order 72-hour holds, suggested Lt. Garlick.A crisis nego a on team is also anasset to working with EDP events,and, of course, training street-level

cops beyond the basics learned inthe academy.

1. Crisis interven on training. Calhoun County, Ala., Memphis, and Houston, areamong the agencies which have developed Crisis Interven on Teams (CIT).CIT members are specialized law enforcement o cers who have 40 hours oftraining and experience in a special-duty assignment, such as responding toemo onal disturbance crisis calls, in addi on to making regular police servicecalls. CIT o cers learn to interact with people with mental illness who are incrisis. Week-long basic CIT training consists of 15 training modules of varyinglengths. These courses, usually given in order, include:

Introduc on to Clinical Issues Rela ng to Mental Illness Introduc on to Psychotropic Medica ons Substance Abuse and Co-Occurring Disorders Post-Trauma c Stress Disorder (PTSD) Cultural Awareness Suicide Preven on Rights and Civil Commitment Law Family and Consumer Perspec ve Trauma c Brain Injury (TBI) Developmental and Disrup ve Disorders of Childhood and Adolescents

Introduc on to Verbal Techniques Borderline and Other Personality Disorders Basic Strategies of De-Escala on Advanced Verbal Techniques and Prac cum Community Resources

Houston police began a mental health unit in 1999. Since then, they haveincreased CIT training to more than 2,100 o cers. In 2012, the Houston PoliceDepartment responded to more than 28,000 mental health calls, resul ng inonly 55 arrests.

Houston, Texas Police Departments Homeless Outreach Team (HOT) Mental HealthUnit Of cer Jaime Giraldo speaks with a homeless man about to be transported to alocal hospital. Of cer Giraldo drives the HOT Mercedes Benz van, painted in classic

black and white police colors and equipped with a powerful wheelchair lift in the rear.

HPD of cers assigned to HOT will use the roomy vehicle as a mobile of ce, as well asa safe transport for homeless people. Source: Houston Chronicle


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2. Mental health o cers. On a smaller scale, many agencies, includingFlorence, Ala., are employing a mental health o cer. A mental healtho cer is called to the scene whenever a suspect is believed to havea mental illness. The o cer is trained to assess whether the person ismentally ill, if the person is dangerous, whether the person can make areasonable decision about treatment, and if the person is undergoingtreatment. The o cer may take the person to a hospital to be evaluated.

3. Mental health courts. Specialized mental health courts could bedeveloped, in which one or a few judges hear all cases involving personswith mental illness and have ready access to mental health professionals.These types of courts are in a be er posi on than a general criminal courtto make adjudica on and sentencing decisions that are tailored to thespeci c needs of each defendant, while s ll protec ng the community.

4. Assisted outpa ent treatment. Studies and data from states usingassisted outpa ent treatment (AOT) prove that AOT is e ec ve inreducing incidents of hospitaliza on, homelessness, arrests andincarcera ons, vic miza on, and violent episodes. AOT also increasestreatment compliance and promotes long-term voluntary compliance forpeople with mental illnesses. These outcomes reduce law enforcementcontact with people with severe mental illnesses.

Participants in the Norfolk, Va. mental health court wait to discuss their progress. Source: hamptonroads.com


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Common SituationsPolice o cers encounter people with mental illness in many di erent types ofsitua ons, in roles that include criminal o enders, disorderly persons, missingpersons, complainants, vic ms, and persons in need of care (see table).

There are many scenarios from a suicidal person, to a barricaded suicide, a

psycho c person on the street, homeless popula ons, domes c violence youname it, said Lt. Garlick.

The ve most frequent scenarios are as follows:

1. A family member, friend, or other concerned person calls the police for helpduring a psychiatric emergency.

2. A person with mental illness feels suicidal and calls the police as a cry for help.

3. Police o cers encounter a person with mental illness behaving inappropriatelyin public.

4. Ci zens call the police because they feel threatened by the unusual behavior orthe mere presence of a person with mental illness.

5. A person with mental illness calls the police for help because of imagined threats.

Roles of People with Mental Illness and Examples

Role Examples

Offender A person with mental illness commits a personal or property crime. A person with mental illness commits a drug crime.

A person with mental illness threatens to commit suicide. A person with mental illness threatens to injure someone else in the delusional belief that the person

poses a threat to him or her. A person with mental illness threatens to injure police as a means of forcing police to kill him (commonly

called suicide by cop).

Disorderlyperson

A family or community member reports annoying or disruptive behavior by a person with mental illness. A hospital, group home, or mental health facility calls for police assistance in controlling a person with

mental illness. A police of cer on patrol encounters a person with mental illness behaving in a disorderly manner.

Missing person A family member reports that a person with mental illness is missing. A group home or mental health institution reports that a person with mental illness walked away and/or is

missing.

Complainant A person with mental illness calls the police to report real or imagined conditions or phenomena. A person with mental illness calls the police to complain about care received from family members or

caretakers.

Victim A person with mental illness is the victim of a personal or property crime. A family member, caretaker, or service provider neglects or abuses a person with mental illness.

Person in needof care

Police are asked to transport a person with mental illness to or from a hospital or mental health facility. Police encounter a person with mental illness who is neglecting his or her own basic needs (food, cloth -

ing, shelter, medication, etc.).


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These are the most common situa ons in which police encounter people withmental illness. However, o cers do not always realize that mental illness isinvolved and may try to handle the situa on as usual (by giving direc ons,issuing commands, or making an arrest) but not get the coopera on orcompliance expected, which may lead to an escala on in tension. Therefore, itis important for law enforcement o cers to learn the signs and symptoms ofserious disorders.

The main examples of serious mental illness are:

1. Psycho c Disorders2. Mood Disorders3. Anxiety Disorders4. Childhood Disorders5. Ea ng Disorders

The following sec ons go into more detail on psycho c, mood, and anxietydisorders.

Psychotic DisordersThe most obvious symptoms of psycho c disorders include paranoia,hallucina ons, and delusions. Other signs include disorganized thinking, speechor language that doesnt make sense, unusual behavior and dress, problemswith memory, disorienta on, changes in ea ng or sleeping habits, energy level,or weight, and the inability to make decisions.

All cases of schizophrenia are considered serious psycho c disorders. While 95percent of violent acts are commi ed by people with no mental illness, those

with schizophrenia are two to four mes more likely to commit violence thanthe average person.

Vincent van Gogh suffered from recurrent psychotic episodes, and committed suicide at age 37. While some psychiatrists point to lobe epilepsy as the diagnosis for his illness, others contemplate whether or not the artist was schizophrenic.


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Sugges ons for encountering a person with acute psychosis, who is ac ng out:

Remain calm. Remember that you cannot reason with acute psychosis. Do not express irrita on or anger. Dont threaten. This may be interpreted as a power play and increase assaul ve

behavior by the person. Dont shout. If the psycho c person seems not to be listening, it isnt because he or

she is hard of hearing. Voices or deluded thoughts are interfering. Dont cri cize. It will only make ma ers worse. Dont bait the person into ac ng out wild threats; the consequences could be tragic. Dont stand over the person if he or she is seated. Instead, seat yourself. Avoid direct, con nuous eye contact or touching the person. Comply with requests that are neither endangering nor beyond reason. This provides

the person with an opportunity to feel somewhat in control. Decrease other distrac ons immediately turn o the TV and radio. Express understanding for what the person is experiencing. Speak quietly, rmly and simply.

Worst Case Scenario: Schizophrenic amputee fatally shot by Houston o cer

A 45-year-old amputee was fatally shot by a Houston, Texas police o cer. The man had losthis le arm and leg because he believed that the devil was in the le side of his body, so hehad decided to lay down on railroad tracks and wait for a train to come and dismember him.(People with paranoid schizophrenia o en see and hear things that arent there.) In 2012,police responded to reports that the man was ac ng out at a residen al care facility. The mancornered a responding o cer with his wheelchair and a empted to stab him with a shinyobject. Another responding o cer, fearing for his partners life and his own safety, shot theman in the head. The shiny object turned out to be a ballpoint pen. Criminal charges werenot made against the police o cer; however, the department was na onally cri cized forthe incident.

Be er Case Scenario: 22-year-old schizophrenic calmed by Bal more o cer

In July 2013, a 22-year-old man with schizophrenia called 911 to report a gunshot to his head.Earlier in the day, he thought hed heard a group leader at his psychiatric rehab program askwho wanted direc ons to his house. The delusion frightened him and by the end of the day,he thought hed been shot in the head. The o cer met him on the sidewalk and shook hishand. She asked him what was wrong, and he responded that he wanted to report beingshot in the head. The o cer asked where he was shot and he pointed to both temples. Theo cer acknowledged that she saw what he was talking about. She asked him if he possessedanything sharp that could hurt her and asked to check his pockets, to which he consented.For the bene t of the man, the o cer pretended to check her databases to ensure thatno one could acquire his address. She asked him how she could make him feel be er, andrepeatedly assured him that no one knew his address and that his gunshot wound wouldbe okay in 4-5 days. She gave his mother a phone number to an emergency hot-line to callin the event of a crisis. The o cer validated the mans concerns, addressed his worries, andde-escalated the situa on.


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Mood DisordersSevere cases of major depressionand bipolar disorder are consideredserious mental illnesses that couldput the vic ms and others safetyin jeopardy. Bipolar disorder is apersistent illness with recurringepisodes of mania and depressionthat can last from one day tomonths. Severe symptoms caninclude recurring thoughts ofdeath or suicide, reckless behavior,impulsiveness, delusions, andhallucina ons.

In bipolar disorder, suicide is asigni cant risk, occurring in 10 to 15 percent of people with Type I or II. Suicidalthoughts and a empts are more likely to happen when the individual is in adepressed state. Other forms of self-harm, such as cu ng and self-mu la on, isalso common in people with bipolar disorder I or II.

Bad decision-making can happen with severe bipolar disorder. There can be extremeirritability. They may start yelling at strangers on the street or get in ghts in publicplaces. Reckless behaviors could also include binge drinking and drug use.

A emp ng suicide, assaul ng another person, stealing, speeding, crea ng a publicdisturbance, and lewd conduct are among the more common ways that someonemight break the law during a bipolar episode.

Worst Case Scenario: Knife-wielding bipolar man commi ed suicide-by-cop in New YorkIn May 2013, a 39-year-old man diagnosed with bipolar disorder bore down on New York o cerswhile screaming Im going to get you; Im going to f---ing kill you. He charged an o cer with a13-inch knife, ignoring commands to drop his weapon. The man came within three feet of theo cer before he was killed by a single shot. The man and his girlfriend had been drinking thatnight when they fought and his girlfriend le their apartment. Realizing she needed clothes, she

agged down a police car. The police o cers accompanied her back to the apartment, where,without warning, the door ew open and the man rushed out with a knife in hand. The manhad two months prior a empted to overdose on his an -anxiety and an -psycho c medica on.Previous domes c incident reports had also been taken.

Be er Case Scenario: Georgia elementary school shooter surrenders to policeThe August 2013 suspect in a Georgia elementary school shoo ng surrendered to policea er ring six rounds in a front o ce. He had nearly 500 rounds of ammuni on with him. Hesurrendered to police a er exchanging gun re with them. It is believed that he took the AK-47from an acquaintances house. The shooter had bipolar disorder and su ered from A en onDe cit Disorder (ADD). He indicated to the schools bookkeeper, who he held cap ve during theincident, he had stopped taking his medicine. The bookkeeper allegedly convinced him to putdown his gun a er explaining to him that she loved him and told him about her own troublesoccurring in her life, saying, Its going to be okay. If she could recover, he could too. A er theytalked, she asked him to put his weapon down. He complied and was taken into custody.

Michael Hall, 20, diagnosed with bipolar disorder, entered an Atlanta, Ga. elementary school with an AK-47. He surrendered

to police after his feelings were justi ed by the school book -keeper, who he held captive during the ordeal.


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Anxiety DisordersSerious anxiety disorders include severe cases of panic disorder, obsessive-compulsive disorder, and post-trauma c stress disorder.

Panic a acks typically begin without warning and at any me driving a car,at the mall, sound asleep, or in the middle of a business mee ng. Symptomsinclude:

Sense of impending doom or danger Fear of loss of control or death Rapid heart rate Swea ng Trembling Shortness of breath Hyperven la on Chills Hot ashes

Nausea Abdominal cramping Chest pain Headache Dizziness Faintness Tightness in throat Trouble swallowing

Complica ons from panic disorders could include depression, increasedrisk of suicide or suicidal thoughts, and alcohol or substance abuse. Peopleexperiencing them may fear they are dying, su oca ng, having a stroke or hearta ack, or simply going crazy. In severe cases, vic ms may develop agoraphobia,an intense and irra onal fear of being in public places and may never leavehome.

Obsession symptoms o en have themes to them, such as fear of contamina onor dirt, having things orderly and symmetrical, aggressive or horri c impulses,and sexual images or thoughts. Signs include:

Fear of being contaminated by shaking hands or by touching objectsothers have touched

Doubts that theyve locked the door or turned o the stove Thoughts that theyve hurt someone in a tra c accident Intense stress when objects arent orderly or facing the right way Images of hur ng their child Impulses to shout obsceni es in inappropriate situa ons Avoidance of situa ons that can trigger obsessions, such as shaking

hands Replaying pornographic images in their mind Derma s or raw skin because of frequent hand washing Skin lesions because of picking at their skin Hair loss or bald spots because of hair pulling

Compulsions include repeatedly washing, cleaning, coun ng, checking,demanding reassurances, and orderliness.


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Post-trauma c stress disorder develops a er a terrifyingordeal that involved physical harm or the threat of

physical harm. It was rst brought to public a en onin rela on to war veterans, but can also resultfrom incidents such as a mugging, rape, torture,kidnapping, child abuse, car accidents, bombings,or natural disasters. External signs and symptoms

include swea ng, depression, easily startled,and angry outbursts. Common side e ects of

an depressant medicine include headache,nausea, agita on, sleeplessness, and sexualproblems.

It takes a lot of mental energy for peoplediagnosed with an anxiety disorder to holda conversa on because their brains areoverwhelmed with anxiety, causing distractedthinking, over-thinking from nervousness, tonguestumbling, lightheadedness, loss of reality, andtrouble listening.

Worst Case Scenario: DC gunman su ering fromPTSD killed 12 at Navy building

In September 2013, a Navy veteran killed 12 people inWashington, D.C. a er su ering a host of serious mental issues,including paranoia and a sleep disorder, as well as Post Trauma c

Stress disorder a er his involvement in the rescue of Sept. 11, 2001 vic ms. Armedwith a shotgun and two handguns, he sprayed bullets from the fourth oor downto the cafeteria area of the Naval Sea Systems Command headquarters. He diedlater during an exchange of gun re with police. Navy personnel had previously beenwarned that the gunman heard voices, and that people were sending microwavevibra ons into his body to deprive him of sleep. He visited two hospitals in the weeksprior to his rampage.

Be er Case Scenario: OCD teen arrested before bombing Oregon high school

In May 2013, an Oregon teenager was arrested a er police got a p that he wasmaking a bomb to blow up his high school. He was charged as an adult with one countof a empted aggravated murder and six counts of manufacturing and possessing adestruc ve device. The suspect allegedly struggles with a rare form of obsessive-

compulsive disorder. Inves gators found six bombs under the oorboards of thesuspects bedroom, along with wri en plans modeled a er the 1999 Columbinea ack.


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Related ProblemsProblems related to mentalillness include homelessness,drug abuse, and alcoholabuse. Approximately one-third of the adult homelesspopula on su ers from severeand persistent mental illness.

They havent been intreatment because they areon the streets, and they dontwant to take their medica onbecause it makes them sleepy,disoriented or confused andthey are afraid theyll getbeaten up and robbed, said

Deirdre Kimble-Charles, acaseworker with the HarrisCounty, Texas Mental Health-Mental Retarda on Authority,in a news account.

Mental disorders prevent people from carrying out essen al aspects of daily life,such as self-care, hygiene, household management, and personal rela onships.Some mentally ill homeless persons live in abandoned houses and burn them down.

Homeless people with mental disorders remain homeless for longer periods ofme and have less contact with family and friends. They encounter more barriers

to employment, tend to be in poorer physical health, and have more contact withthe legal system than homeless people who do not su er from mental disorders.

There is a strong rela onship between residency in homeless encampments anddual diagnoses of addic on and mental illness. E ec ve strategies to get people othe streets include long-term integrated treatment programs and comprehensivecase management. Many communi es have groups ac vely working to increasestate and local government funding of these services.

Nega ve interac ons between police o cers and homeless people can beavoided through educa onal e orts to change police culture and a tudes towardhomelessness. Invi ng homeless advocacy groups to help design and teach thecurriculum can be very useful in building posi ve inter-agency rela onships.

Police involvement in planning community-wide strategies to end homelessnessis also bene cial. Community mee ngs are a good way to express what resourcesyour department can bring to the table as well as any limits on your involvement.

Why do we need police o cers doing this? Because a lot of mes police o cers arethe rst ones called, said Houston, Texas Mayor Annise Parker in a news account.

Up to 30 percent of daily service calls to the San Luis Obispo, Calif. Police Department are for

homeless-related activity. The department has applied for the Justice and Mental Health ProgramGrant, which would allow for Transitions Mental Health Association, SLO County Behavioral Health

Services, and the Police Department to work together. It helps you look for and understand theirmindset because they may be schizophrenic or have some other kind of mental disorder, said

Of cer John Villanti. With the grant, a mental health professional would patrol with the CAT Team onan ongoing basis. Source: Central Coast News


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Theres an angry property owner downtown, who says, Somebody is sleepingon my front steps. Do something! or Someone is urina ng on my building. Dosomething! These people dont belong in jail, they need assistance.

Approximately 25 percent of sheri s o ces and local police departmentshave wri en policies for contacts with homeless people. These policies shouldbe developed to include training on handling homeless people with mental

illnesses, including CIT training. Policies should also include procedures forcasual contacts and arrests, as well as details about how to give no ce to illegalcampers and deal with the property of homeless people. Appropriate recordkeeping can later help assess the e ec veness of the policy.

Some police departments have specialized units to deal speci cally withhomeless people. Other agencies allow outreach workers to accompany themon patrol through areas frequented by homeless people. In Fort Lauderdale, Fla.,police o cers on the Homeless Outreach Team learned that wearing a uniformand driving a marked patrol car made it easier to contact homeless people being approached by someone in plain clothes and an unmarked patrol car

made them fearful. O cers in San Diego partner with mental health cliniciansin a Psychiatric Emergency Response Team. O cers in Santa Monica, Calif.,created a specialized unit known as the Homeless Liaison Program to reach outto transients and refer them to housing providers, job placement services, andtreatment programs for mental illness and substance abuse disorders.

Frequently, police of cers encounter mentally ill people who have not committed a crime, or the crime was of a petty,non-violent nature. Of cers attend Crisis Intervention Training to learn alternative methods (other than arrest) to

dealing with persons with mental illness. To become a CIT of cer, of cers participate in an intensive 40-hour trainingclass, which revolves heavily around role-playing exercises where professional actors and actresses are used to

play the part of the mentally ill subjects. The training is also comprised of site visits to local mental health centers andtreatment facilities, meetings with mental health professionals, family members of mentally ill people, and consum -ers of mental health services.


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Police HomelessOutreach Programsin the ROCIC Region:

Homeless Outreach TeamFort Lauderdale, FLThe Police Homeless

Outreach Team iscomposed of a police o cerand a volunteer from theBroward Coali on for theHomeless who seek tobuild rela onships withthe homeless in hopes ofinforming them of various

resources and assistance that can help them become self-su cient. The volunteeris a formerly homeless person who can iden fy with the struggles many face butalso to o er personal anecdotes. The police o cer wears the uniform becauseit conveys authority and safety once the rela onships are established. Also, thehomeless were more recep ve of this approach as opposed to the o cer andvolunteer working without any visible iden ca on.

In addi on to this program, the police department hopes to break the cycle ofhomelessness once individuals arrested for crimes are discharged so they are notsimply released to the streets again. When an individual is booked, police ask certainques ons. If the police believe that the person is homeless, then they require himor her to ll out a homeless referral form which goes to the Broward County SocialService Outreach Team. The homeless are contacted by social workers with thegoal of placement in appropriate social service upon release from jail.

Clearwater Homeless Interven on ProjectClearwater, FLThe CHIP program has a community policing substa on which is housed in theshelter and which also serves as home to the Clearwater Police DepartmentsDowntown Bicycle Team. In line with Clearwaters tradi on of proac ve communitypolicing, o cers on bicycles are patrolling the downtown area and ge ng to knowthe residents, business owners, and also the homeless popula on. The Bike Teamis taking an ac ve role in referring clients to CHIP, as well as enforcing the rules ofconduct at the shelter. The shelter provides homeless ci zens with opportuni es tobecome self-su cient as well as a day service that serves individuals, giving them

somewhere to stay during the day hours.Homeless Assistance Collabora veNew Orleans, LAThis ini a ve began in the fall of 2004 to e ec vely handle homeless persons andto establish an alterna ve to arrest for minor o enses. O cers collaborate withUNITY (nonpro t that organizes 63 of the areas homelessness organiza ons) tomove homeless people into permanent housing. O cers are trained to call for amarked NOPD mobile assistance unit when approaching a homeless person. Theunit helps homeless people with their immediate concerns and provides referralsand assistance to a shelter, hospital, or substance abuse program.

Volunteers with the Homeless Assistance Collaborative help homeless men into a waiting New OrleansPolice Department HAC van to be taken to Travelers Aid for assistance.


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Homeless Outreach andProac ve Enforcement(HOPE Program)Atlanta, GAThe program is targeted towardsthe high levels of homelessindividuals at the Harts eld

Jackson Atlanta Interna onalAirport. The o cers assigned tothe airport precinct and selected tobe HOPE program liaisons receivetraining in crisis interven onfrom licensed psychologists. Theo cers are equipped with waysto assist homeless people andare trained to become a referralsystem to various local socialservice agencies.

Rescue Mission ProgramNashville, TNThe Metro Police started this program to assist homeless people in ge ng busfares out of the city. Through the program, homeless people and others strandedin the Nashville area are referred to the private sector, which purchases thebus ckets. The goal of the program is not to rid Nashville of the homeless butto provide help to those in need. The program works in conjunc on with theNashville Downtown Partnership.

Homeless Project O cerFaye eville, NCThis o cer is responsible for the iden ca on and classi ca on of homelesspersons. The o cer serves as a resource to homeless people in the area,assis ng them with iden ca on, meals, shelters, and other basic necessi es.In addi on to these du es, the o cer also has to ini ate and maintain trespassagreements for vacant homes, lots and businesses a er opera ng hours toreduce criminal ac vi es.

Homeless Outreach Partnership Enforcement (HOPE) UnitRichmond, VAThe du es of this unit include policing, serving, and protec ng the homelesspopula on in the Richmond area. The unit consists of a sergeant, three o cers,and City Department of Social Services social work specialist dedicated tohomeless services. The unit patrols areas usually populated by homelessindividuals and assists people by providing them with referrals for homelessservices.

Street Outreach Program (STOP)Birmingham, ALThis ini a ve is funded by HUD and provides two CDM social workers to work withthe City Ac on Partnership, which is Birminghams Business Improvement District.

Fayetteville, N.C. Police Of cer Stacy Sanders offers a homeless man a donated jacket under -neath the Person Street Bridge spanning the Cape Fear River. Im not surprised by the num -

bers. Im not surprised by the children and the families that are homeless but I am surprised bythe lack of resources, said Of cer Sanders, the departments homeless specialist. The thing

that bothers me the most is that my hands are limited. Source: newsobserver.com


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Altered Mental StatusFrom Medical IllnessesLaw enforcement o cerso en interact with peoplewho demonstrate erra c andpoten ally violent behavior

persons who have an alteredmental awareness of theirsurroundings. These types ofbehaviors are o en dismissedas alcohol intoxica on or purepsycho c episodes; however,the behavior may actually bea ributed to a medical illnessor an adverse reac on to atrauma c event, such as withAlzheimers disease, diabe cemergencies, seizures, andtrauma vic ms. For instance:

In July 2013, the Santa Fe, N.M.police came under heavy cri cism a er depu es forced a woman who washaving a diabe c episode onto the road pavement, handcu ed her, and leher in the back of a police unit where she almost went into diabe c coma. Shehad been a minor tra c accident, and police thought she was drunk. She wassubsequently forced out of her car a er she was unresponsive to demands toopen her door. Police eventually phoned paramedics, who treated her for lowblood sugar.

The following are common medical illnesses that could be misconstrued asalcohol or drug intoxica on or as a mental disorder.

Alzheimers Disease

The challenges in dealing with a person with progressed Alzheimers diseaseis that he or she may not be able to ask or recognize that they need help. Theycould walk or drive for hours unaware of the passage of me or their owndisorienta on. They even may a empt not to be found by searchers.

Signs and symptoms of Alzheimers disease include repe on, paranoia,anxiety, loss of inhibi on, rummaging, hiding or hoarding objects, pacing anddge ng, and wandering.

Incidents involving Alzheimers pa ents include driving di cul es, falsereports to 911, domes c violence, homicide, suicide, indecent exposure,shopli ing, abuse/neglect, poisoning, choking, overdoses, falling, cookingaccidents, trespassing, res, and vic miza on.

In 2010, the Greenwich, Conn. Police Department began participating in Project Lifesaver,a program that helps law enforcement locate people who wander away due to a medical

condition, such as autism, down syndrome, or dementia. People with those conditions wear

a radio transmitter attached to a bracelet, and police use a hand-held antenna to pick upthe signal from the device. The equipment was provided to the department free of charge.Source: greenwichtime.com


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Diabe c EmergenciesA diabe c person in insulinshock o en appears to bedrunk. He or she is slow torespond to any s muli, slurswords, and is disoriented.These persons need to raisetheir blood glucose level withorange juice or other high-sugar foods.

Hyperglycemia or diabe ccoma is the opposite ofinsulin shock. Symptomsinclude disorienta on andsweet-smelling breath thatis some mes mistaken forthe by-products of alcoholintoxica on.

Diabe c emergencies may be more prevalent in the less privileged popula onsbecause of lesser access to medical care.

SeizuresSeizures may cloud awareness, block normal communica on, produce avariety of undirected, uncontrolled, unorganized movements, and may causeloss of bladder or bowel control. The person will not comply with instruc onsfrom the o cer whether the person has had an absence seizure (a period ofunresponsiveness, but with eyes open) or the classic full-body shaking. Theactual seizing consumes a lot of energy resul ng in a pos ctal (drowsy) statea er the seizure, during which the pa ent is unresponsive to verbal s muliand appear to be under the e ects of alcohol or drugs.

TraumaLaw enforcement o cers observe the a er-e ects of trauma c injury ona daily basis, e.g., high-speed crash vic ms or an aggravated assault vic m.Injuries will alter a persons level of consciousness. Symptoms of a trauma cbrain injury include behaving inappropriately and disorienta on.

Elderly persons on blood thinning medica on and chronic alcoholics are atgreater risk of cerebral hemorrhage from simple falls from a standing posi onand should be immediately referred to EMS.

Santa Fe, N.M. Police Department came under heavy criticism after mistaking a woman havinga diabetic attack for a drunk driver. Source: Police Magazine


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Conclusion

The trick when dealing with people in crisis is tocalm the situa on and take your me, advisedLt. Garlick. A quick triage star ng with medicalissues, then environment, diet, sleep, and nallytrauma is most helpful in understanding whatmay be happening.

The thing to remember is that states are reducingbeds and driving people into local treatment,and 67 percent of mentally ill people dont seektreatment because they do not have a suppor vefamily.

We need more places to permanently commitpeople so that they have a clean place to live, getfood, and receive medica on. Then they can livea decent life. We also need to look at everyonesbudget, not just a par cular agency, because weare spending a lot of money in total dealing with this problem in a most ine cientmanner.

It is cri cal that law enforcement o cers tailor responses to local circumstances.You should jus fy each response based on reliable analysis of the situa on. In mostcases, an e ec ve strategy will involve implemen ng several di erent responses.Agencies will also have to partner with their community, as law enforcementresponses alone are not enough to solve the problem.

Lt. Jon Garlick, Mental Health Of cer withthe Calhoun County, Ala. Sheriffs Of ce


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Lt. Jon Garlick, Calhoun County, Ala. Sheriffs Of ceEmail correspondence

DSM-V Diagnostic and Statistical Manual of MentalDisorderswww.dsm5.org

People with Mental Illnesshttp://www.popcenter.org/problems/mental_illness/print/

Law Enforcement Responder: Principles of EmergencyMedicine, Rescue, and Force Protectionhttp://books.google.com/

Keeping the Peace: Police Discretion and Mentally Ill Personshttps://www.ncjrs.gov/pdf les1/jr000244c.pdf

Mental Illness Impacts Law Enforcement Resourceshttp://www.nami.org/

Law Enforcement and People with Severe Mental Illnesshttp://www.treatmentadvocacycenter.org/storage/docu -ments/bp_law_enforcement.pdf

How to Stop Suicide by Cophttp://www.psmag.com/health/how-to-stop-suicide-by-cop-27758/

Across Nation, Unsettling Acceptance

When Mentally Ill in Crisis are Killedhttp://www.pressherald.com/

Police Of cers Attitudes Toward and DecisionsAbout Persons with Mental Illnesshttp://psychiatryonline.org/data/Journals/PSS/3606/49.pdf

October 2011 FBI Law Enforcement Bulletin:Responding to Persons with Mental Illnesshttp://www.fbi.gov/

Guest Post: A Successful Story -A Police Of cer and a Person with Schizophreniahttp://bipolarbandit.wordpress.com/

Schizophrenia - Dealing with a Crisishttp://www.world-schizophrenia.org/publications/15-crisis.html

Adult Bipolar Disorder: When to Intervenehttp://www.netplaces.com/adult-bipolar-disorder/

Knife Psycho Killed by Cops was Bipolar http://www.nydailynews.com/news/crime/

Authorities: Georgia Shooting Suspecthad Nearly 500 Rounds of Ammunitionhttp://usnews.nbcnews.com/_news/

Obsessive-Compulsive Disorder http://www.mayoclinic.com/health/

Panic Attackshttp://www.of cer.com/article/10249719/panic-attacks?page=3

What is Post-Traumatic Stress Disorder (PTSD)?http://www.nimh.nih.gov/health/

As Mental Illness Permeates Streets, Police, Jail Strugglehttp://www.houstonchronicle.com/news/

Police Homeless Outreach Programshttp://www.egovlink.com/

Homeless Encampments

http://cops.usdoj.gov/Publications/e011013251-Homeless -Encampments.pdf

Police Experiment with Getting Mentally IllHelp Instead of Handcuffshttp://hamptonroads.com/2004/11/police-experiment-get -ting-mentally-ill-help-instead-handcuffs

Sources of Information

Law Enforcement and the Mentally Ill (3)

Documents

Transcript of Law Enforcement and the Mentally Ill (3)