By Dr. Laurence Miller
Like it or not, in almost every community there are citizens with one or more kinds of mental disorder, many of them homeless, and most of them not receiving any effective treatment. Dealing with these individuals is a necessary part of police patrol work. Many officers actually feel less comfortable handling mentally ill citizens than they do criminal suspects because the latter, ironically, are often more predictable and more clearly responsible for their behavior than the former. There also remains the socially stigmatized, general “creepiness factor” of the mentally ill which most people, including most cops, share.
Nevertheless, surveys show that most officers would welcome special training in dealing with mentally ill citizens. Accordingly, this 4-part series will provide insight into the variety of symptoms, syndromes, and disorders that officers are likely to encounter in their patrol work. I’ll also provide you with some practical strategies for dealing with mentally ill citizens in a way that preserves the balance between respect for individual rights and dignity, and enforcing the law and maintaining social order within the community.
I like to tell the officers in my training courses that they’re already the best “practical psychologists,” because they understand and utilize, on an intuitive basis, much of the information that I discuss in my more clinical-sounding lingo. But hopefully, gaining a little more formal diagnostic insight should help put many of these behavioral syndromes in a clearer context, so that an officer’s actions on the street can become even more effective in maintaining order, enforcing the law, and enhancing the community’s overall quality of life.
Law enforcement response to the mentally ill
To put things in context, it’s important to understand some of the facts and statistics regarding mental illness and the police response to mentally ill citizens. Approximately 5 percent of the American population has some form of serious mental illness. In jail or prison populations, this proportion rises to 16 percent. Almost three-quarters of these mentally ill inmates have a coexisting substance abuse problem. Most mentally ill persons are not violent, but there seems to be a somewhat higher ratio of violence among the seriously mentally ill than in the general population. When mentally ill persons do commit a violent crime, the victim is familiar to them in more than half the cases; indeed, most perpetrators of violence have some personal connection with their victims. However, the mentally ill are far more often the victims of crime than the perpetrators, and are three times as likely to be crime victims as ordinary citizens.
Across the United States, mental health calls account for 5 to 10 percent of calls for police service, ranking on a par with robbery calls. A significant number of these mental health calls relate to aggressive behavior, making them at least as dangerous as robbery calls. A large number of mental health calls overlap with domestic violence calls, which are themselves potentially dangerous situations for responding officers. Arrest rates for mentally ill suspects are about the same as for domestic violence suspects, and both are higher than rates for the general population. Displayed disrespect for officers – contempt of cop, or COC – is equally likely to increase arrest rates for all suspects, with or without mental illness.
Surveys show that officers tend to view mentally ill subjects as more dangerous and less in control of their actions than other citizens. While the mere presence of a psychiatric disorder does not necessarily increase a citizen’s risk of violence, the risk is highest for psychotic subjects experiencing paranoid delusions and persecutory command hallucinations. Substance abuse multiplies the violence risk among the mentally ill, and dual diagnosis (substance abuse plus mental illness) subjects are more likely to be taken into custody, either because of their greater violence risk or because they are more likely to be accepted by hospital receiving facilities. Officers are more likely to use civil commitment as an alternative to arrest and jail detention if they believe that the mental health system will accept potentially violent cases.
Signs and symptoms of abnormal behavior
In medicine, a sign is an objective observation or finding on a clinical examination. Examples include a limp while walking, high blood pressure on a cuff reading, or disorganized and delusional speech content during conversation. A symptom is a subjective experience that is reported by the patient, such as pain in the knee, throbbing headaches on exertion, or voices in his head telling him to fight off the evil forces threatening him.
A syndrome is a standard cluster of signs and symptoms that occur in a regular pattern, are typically associated with a particular causal factor, and/or occur in a particular subset of the population. Examples include degenerative arthritis of the knee in an ex-athlete, hypertensive headaches in an overweight woman with a high-salt diet, and paranoid schizophrenia in a homeless young man who abuses amphetamines and alcohol. A syndrome becomes a disorder when it interferes with important life functions of the patient, such as shortening life, decreasing the quality of health and well-being, or interfering with job, family, or social functioning.
Although different syndromes have different symptom clusters, there are some general signs of mental disorder that police officers should recognize (Pinizzotto & Deshazar, 1997; Russell & Beigel, 1990; Will & Peters, 2004).
General inappropriateness of behavior may be a sign of mental illness, although it may also be due to intoxication or even just youthful exuberance. Individuals with mental disorders tend to have their cognitive and behavioral gyroscopes set to extremes, characterized by either inflexibility and rigidity, or impulsivity and unpredictability. Emotions may range from elated to depressed, calm to panicked, and there may be an unnatural changeability of mood that is inconsistent with the circumstances. Attention, concentration, and memory may be impaired, either due to an organic brain syndrome or heightened distractibility from the anxiety of an internal dialogue. Severely disturbed subjects may be disoriented for time (“What day is this? Is it morning or afternoon?”), place (“Do you know where you are now? Where do you live?”), or person (“What’s your name? How old are you?”).
Speech may be tangential, flitting from topic to topic without a clear connection between them, or it may be circumstantial, remaining on, or returning to, the same topic, even after the conversation has moved on. Perseveration refers to abnormal persistence or repetition of speech or behavior. Pressured speech occurs in a rapid-fire, jumbled form, as if the person is rushing to spill out all the words as fast as possible; conversely, speech output may seem abnormally slow, as if the subject is weighing and measuring every word.
Aphasia refers to a group of organic language disorders characterized by various disturbances in comprehension and expression. Most commonly seen in elderly persons with strokes or dementia, subjects with receptive aphasia fail to comprehend normal speech, and may appear to be ignoring or defying the officer’s commands. The speech output of subjects with expressive aphasia may seem garbled and confused, and in severe cases may be limited to one- or two-word answers that are off the mark. Aprosodia refers to an abnormally flat and unexpressive tone and cadence of speech, even where the vocabulary and grammar are essentially intact. Some subjects may remain completely mute, either due to organic language disturbance or psychotic fear of saying anything. Remember, too, that perfectly healthy suspects may clam up to avoid incriminating themselves or just to be obstinate.
What someone is thinking (a symptom) can usually only be inferred from what they are saying or doing (a sign). Flight of ideas refers to a rapid jumping around of thought processes that often occurs in manic states or as part of the routine of certain “gonzo” stand-up comics. Paranoia refers to the belief or feeling that one is being plotted against or harmed (assuming these feelings don’t have a basis in fact). Grandiose ideas relate to one’s inflated view of his or her own self-importance, and ideas of reference cause the person to regard otherwise neutral events as pertaining specifically to him or her.
These four cognitive symptoms often occur together in several types of bipolar manic or schizophrenic syndromes, e.g.,
“They must be out to destroy me [paranoia] because they know I’ve discovered the secret to world peace [grandiose idea], and the proof is that TV show about the Vatican where I could tell they were talking about me [idea of reference], and maybe I should go on TV myself, or maybe I should get a lawyer and sue the networks, or maybe I should network with other people who believe in world peace, because Jesus caught the fishes with a net, he worked with a net [flight of ideas] .”
Delusions are false beliefs that are clung to in spite of objective evidence to the contrary. Hallucinations are abnormal sensory experiences that are most often auditory in mania and schizophrenia states, visual or tactile in organic brain syndromes, or more rarely, may affect the other senses as well. Many patients have somatic delusions, in which they believe their bodies are infected, decaying, or changing in size and shape. Hallucinations and delusions may occur together, as in a paranoid subject who hears voices telling him he is targeted for termination, consistent with his belief in a government plot to destroy him, or they may occur separately.
The personal and social behavior of seriously mentally ill persons is usually observably abnormal. Social interactions may be suspicious and guarded, or confrontational and combative. Subjects may be uncooperative or overly compliant. They may appear confused or disoriented. In some cases, they may show a hair-trigger response to the smallest provocation, becoming terrified or aggressive or both, and requiring restraint for their own safety and/or that of others.
Responding to mentally disturbed citizens: Basic strategies for patrol officers
Many of the basic techniques I described in my previous column for interacting with ordinary citizens may also be used with mentally ill subjects. But, given that these subjects may not respond in the normal manner to normal interventions, some special considerations apply to dealing with mentally ill citizens.
Proper response to the mentally ill begins with the call. Sometimes, officers will just come upon a situation involving a mentally disordered subject, but in many cases, such calls come over the radio, usually in the form of someone “acting crazy” on the street or in a store or other public or private location. Such calls should be answered by more than one officer, preferably in uniform, so there is no doubt in the subject’s mind as to the identity of the officers. Sometimes, this alone can quell a potentially violent situation.
The first priority is ascertaining the physical health and safety of the subject and others who may be at the scene. If there is no immediate danger to self or others, when first approaching the subject, keep your distance and move slowly. One officer should be the talker and the rest keep silent, to avoid simultaneous conversation, which will likely be confusing and irritating to an already disturbed subject; the other officers can control any crowds that might contribute to a spectator circus. Employ the technique of a calm show of force: by a combination of strength of numbers and a firm but easygoing manner, make it clear to the subject that you would prefer him to comply willingly and will respect his decision to do so, but you are prepared to use physical restraint if he leaves you no other choice.
For many disturbed subjects, this approach accomplishes the dual purpose of imposing some external control over an otherwise overwhelming experience, and at the same time, leaving an otherwise resistant subject a face-saving way out of appearing weak by “giving in” – after all, he’s facing six cops. Also, many mentally ill subjects are so disturbed that an otherwise intimidating show of force by just one or two officers may be completely missed or ignored. For example, a drawn baton or firearm may have little meaning to an already frightened, angry, hallucinating subject.
In line with this, provide reasonable assurance that you’re there to make things better, not worse. With angry and agitated subjects, avoid unnecessary threats and try to meet hostility with deflection and de-escalation, but be cautious about letting down your guard. Remember, mentally disordered persons are unpredictable, so never underestimate a subject’s size or appearance – it’s amazing what a burst of adrenalin can enable a terrified or enraged person to do. Even though the subject appears disturbed, try to keep your conversation geared to that of a normal, reasonable person. As much as possible, don’t lie, deceive, unnecessarily manipulate, or treat the subject like a child – remember, “just because they’re crazy doesn’t mean they’re stupid.”
If the subject expresses delusional thinking, neither dispute nor agree with the content. Arguing against someone’s perception (“there’s no plot to kill you, pal – it’s all in your head”) is likely to be irritating and alienating, while too-quickly agreeing with the delusion (“yeah, they’re tying to get you, but we’ll take care of it”) or hallucination (“sure, sure, we see the guys with the trenchcoats, too”) may be taken for the phony camaraderie that it is, further inflaming the subject by convincing him that he can trust no one and is being manipulated by everyone. A better strategy is present yourself as an honest broker who frankly can’t pretend to see or believe what the subject does, but is prepared to keep an open mind in the service of helping the subject:
“Sir/Ma’am, I really don’t know if they’re after you or not, but if you think they are, let’s figure out how to keep you safe for now, okay?”
It’s a good idea to record the gist of the subject’s delusional content because this may prove valuable to both the criminal justice and mental health follow-ups, especially if this involves overtly paranoid, aggressive, or suicidal ideation. Note any threats made, especially if directed against specific persons or agencies. If no arrestable offense has been committed and the subject is basically cooperating, exercise caution, but utilize the same tact and respect as you would with any citizen. If the situation seems to be resolved and safe, you may use your discretion as to whether to send the citizen peaceably on his/her way. If you’ve called for help, even if things seem to have calmed down in the meantime, stay with the subject until backup or medical services arrive. Sometimes it may be your role to transport the subject to the appropriate facility, so know which facilities exist in your community.
Involuntary commitment of a mentally ill citizen who is a danger to self or others may be made by law enforcement or medical personnel in most jurisdictions. In addition, if a mentally ill citizen commits an offence – in most cases a misdemeanor such as public urination, panhandling, or petty shoplifting – you may use your discretion as to whether or not to make an arrest. However, many situations can be peacefully resolved by the use of good communication strategies and basic “street psychology.”
Read: Part 2 - Part 3 - Part 4
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Disclaimer: This article is for educational purposes only and is not intended to provide specific clinical or legal advice.
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