Dealing with mentally ill citizens on patrol, Part 2
In Part 1 of this 4-part series, I discussed general signs and symptoms of mental disorder and provided some practical strategies for dealing with mentally ill citizens. Part 2 offers more specific advice for handling subjects with specific kinds of anxiety, mood, and psychotic disorders. Again, the purpose is not to be a comprehensive course in psychopathology and psychotherapy, but to provide practical guidelines for street-level crisis intervention that all officers can utilize effectively.
Anxiety and Mood Disorders
For most people, our normal mood is neither especially happy or sad, angry or loving, agitated or calm, but just a steady sense of what I call provisional well-being: the overall feeling that everything right now is basically okay. It’s like the feeling between meals when we’re neither hungry nor full, when in fact, we’re too preoccupied with what we’re presently doing to pay conscious attention to our digestive – or emotional – states at all. All healthy people show a range of moods, getting periodically happier, sadder, angrier, calmer and so on, in response to various life circumstances, and some otherwise normal people seem to be dispositionally predisposed to either the cheerier or more dour side of the mood spectrum. Like any trait or syndrome, it is the extremes of mood that characterize a disorder, especially when these mood disturbances impair healthy life functioning or produce unreasonable conflict with others.
Clinical features of mood disorders. Mood disorders generally fall into the two broad categories of anxiety disorders and depressive disorders, although the symptoms often overlap. Anxiety disorders are characterized by heightened worry, fear and arousal. Generalized anxiety disorder (GAD) involves a pervasive feeling of anxiety that is not necessarily tied to any specific event or circumstance, sometimes referred to as “free-floating anxiety.” These individuals are always anxious about something, although the level of anxiety may wax and wane in response to different situations. Others may perceive these individuals as never being able to relax or be at peace.
Some individuals, with or without GAD, may suffer from panic disorder, which involves brief episodes of extremely elevated physiological arousal and fear. The individual may experience a racing, pounding heart, profuse sweating, rapid, shallow breathing, numbness and tingling in the face and extremities, and faintness or lightheadedness – all the hallmarks of sheer terror. Many subjects fear they will pass out during an attack, although actual loss of consciousness is exceedingly rare. The attacks may occur in response to certain events or they may happen randomly “out of nowhere.” Panic attacks are also likely to occur in the context of depression, often in response to perceived abandonment or loss of support.
If the anxiety and panic are associated with particular places or situations, the individual may develop one or more phobias, which are irrational fears of particular persons, places, or things. Note that these are not delusions, because the person usually recognizes that the fear is not based on anything real, yet he or she feels powerless to control it and must avoid the feared situation to forestall panic. Thus, sufferers often feel demoralized and out of control at not being able to will themselves out of what they know to be irrational fears. Phobias may be generalized, involving fears of a wide variety of people, places, or things (that are usually found to have some elements in common), or they may be quite specific, e.g. to a particular room, class of objects, or type of animal.
Posttraumatic stress disorder is a severe anxiety disorder that arises in reaction to a specific traumatic event and is characterized by a standard set of symptoms, including heightened physical arousal, intrusive recollections or images of the traumatic event, nightmares about the traumatic event, numbing or dissociation to block out the disturbing thoughts or imagery, and a general restriction of life activities. In some cases, without knowing the subject’s history, this may be confused with other psychotic or mood disorders.
Mood disorders are generally classified into unipolar and bipolar types, depending on whether the extreme changes in mood are in one direction (down-depressed) or both directions (down-depressed and up-elated or up-angry). Major depressive disorder is characterized by episodes of depressed mood that may last for weeks or months at a time. In severe cases, the individual may be virtually immobilized. Subjects often feel dejected, demoralized, helpless, and hopeless. Sleep and appetite may be impaired; alternatively, some individuals become hypersomnic (sleep virtually all the time) or may binge-eat. Concentration and memory may be affected to the point where individuals feel they are becoming demented. Gone is any motivation or enthusiasm for work, play, or family activities and the individual may describe a pervasive fatigue and lack of stamina that makes even simple tasks seem overwhelming. Accompanying emotions may include anxiety, panic, irritability, or anger. The disorder usually occurs in cycles over the lifespan, and fortunately, in most cases, is very responsive to proper treatment.
Dysthymic disorder is a more persistent, but less severe, mood disorder. Such individuals mentally limp through life, able to perform sufficiently to get by at work or at home, but experiencing little pleasure or excitement from anything they do – the “walking wounded,” leading a drab, joyless existence. Many of these individuals will deny being depressed per se, but report that they’ve never known what it feels like to be happy. Some individuals with major depression will recover from their severe episodes, but only to a bland baseline state of dysthymia, rarely experiencing anything that could be called a happy or even normal mood.
Bipolar disorder, also known as manic-depressive illness, is characterized by extreme shifts in mood, from elation to depression, usually with an absence of normal mood in between: for such individuals, there are only highs and lows, no middle range.
The manic phase usually begins with the individual feeling energized and overconfident – “pumped.” He becomes hyperactive and grandiose, spinning all kinds of half-baked unrealistic plans, but is too impulsive and distractible to follow through on any of them. Thinking and speech become rapid and pressured. Need for sleep decreases and the individual may be hypersexual – all appetites are on sensory overdrive. The general impression is of someone on stimulant drugs, and indeed, such individuals may abuse amphetamines, cocaine, or alcohol to enhance the natural high and try to keep it going.
At the beginning of the manic phase, the individual may appear quite engaging and entertaining, but as the manic phase progresses, he becomes increasingly short-tempered, irritable, anxious and paranoid. Inevitably, the crash comes as the individual cycles into the depressed phase. At this point, he may increase his use of stimulants to try to prolong the high, but eventually even this isn’t enough to stave off the depressive avalanche. Suicide is a distinct risk at this stage. In other bipolar patients, the manic episodes do not involve much elation at all, but are characterized mainly by irritability, anger and paranoia, and may be misdiagnosed as schizophrenia.
Law enforcement response. The most frequent law enforcement crisis intervention context for an anxious or depressed subject is potential suicide, although depressed subjects are frequently seen in correctional and other institutional settings, as well as on daily street patrol. The first priority is always safety. Since police response is often associated with some type of confrontation in most people’s minds, be sure to assess for suicidal ideation and emphasize the subject’s wellbeing: “I’m officer Smith and this is officer Jones. We’re here to make sure you’re okay and to get you any help you need right now.”
Violence against others is rare in unipolar depression, although it may occur as part of a “suicide pact” with another person, usually an elderly couple with a serious illness or disability. Violence against police officers is a more likely risk for bipolar manic individuals who may be angry and delusional. Move slowly and take your time, avoiding any unnecessary intimidation. Use verbal and nonverbal calming techniques, and employ cautious physical restraint where necessary. Subjects in a manic state may not initially intend to attack you, but may be subject to explosions of anger on hair-trigger provocation. And if they do get physical, you’ll be dealing with a huge adrenalin factor and it’s going to take a lot of force to keep this person under control, so injuries on all sides are a distinct risk. In these cases especially, your judicious use of verbal and nonverbal de-escalation strategies can make the difference between a subject who gets talked-down and treated at a hospital for his mental disorder vs. a subject who gets taken-down and carted off to jail for assaulting an officer. Assuming no arrest is called for, if the subject requires further disposition, transport him or her to an appropriate receiving facility or call paramedics to do so.
Psychoses: Schizophrenia and Other Delusional Disorders
Psychotic disorders comprise a group of syndromes which share the common feature of a significant break with reality, characterized by severe disturbances of mood, thought, and goal-directed action. The most common form of psychotic disorder is schizophrenia, which is a progressive syndrome, usually first presenting in adolescence or early adulthood (although childhood forms occur), and characterized by delusional thinking and the presence of hallucinations, which are typically auditory (hearing voices), and more rarely, visual (seeing things). Untreated schizophrenics may suffer episodic bouts of delusional and hallucinatory psychosis, between which they may appear simply odd or weird, unable to maintain any consistent work or other activity.
Many of these individuals swell the ranks of the “street people” comprising a proportion of an officer’s patrol area in any major metropolitan jurisdiction. Although diagnostic overlap is common, schizophrenia may be seen in several forms, including the paranoid type, characterized mainly by delusions of persecution and accusatory hallucinations; the disorganized type, characterized by general aimlessness and lack of contact with reality; the catatonic type, which is more commonly seen in institutional settings because of their near-immobility; or the undifferentiated type, which may comprise features of the other three classifications or show additional symptoms, often appearing “just crazy.”
Delusional disorders are distinguished clinically from schizophrenia by the fact that the affected individuals may function adequately in most life areas despite the presence of isolated, fixed ideas, which themselves are sufficiently out of sync with reality to qualify as delusions. Thus, a movie fan convinced that a starlet is in love with him would have an erotomanic type of delusional disorder. A grandiose type of delusion would involve the belief that one has the true secret for world peace, if only he could get before the UN General Assembly and tell everyone. Persecutory delusional disorder would characterize the individual who believes that “they” (whoever they are) are after him (often for the purpose of stealing or silencing his grandiose idea). The jealous type of delusion would apply the husband who is absolutely convinced that his wife is having an affair despite no shred of hard evidence. Someone convinced that his body is decaying from within, shrinking or expanding, or that radio waves are changing his skin color or brain patterns might be suffering from the somatic type of delusional disorder.
Psychotic disorders: Risk factors for violence. Although not intended to needlessly stigmatize the mentally ill, clinical and research evidence to date does suggest that subjects with schizophrenic disorders are at greater risk for violence than the population at large. The rate of schizophrenia is three times higher in prisons than in the general population, although this may reflect differential rates of arrest or access to competent legal representation, as untreated mental illness is typically associated with poverty and lower social status. When asked to describe their own behavior, the prevalence of self-reported violence is five times higher among schizophrenic subjects than among the general population.
Paranoid schizophrenic subjects may be an especially dangerous group. One study investigated the arrest records of paranoid schizophrenic former psychiatric patients who attempted to gain access to the U.S. President or other high government officials. It was found that one in seven had been arrested for murder or aggravated assault during the 9 to 12 years following their discharge from mental hospitals where they had been committed.
Certain factors serve to increase the risk of violence among psychotic subjects. Some of these are associated with generic violence risk factors such as access to weapons and co-existing substance abuse. More syndrome-specific risk factors include the presence of persecutory delusions which may impel psychotic subjects to lash out as a way of protecting themselves – a “preemptive strike.” Also, command hallucinations that order the subject to use offensive or defensive aggression are an important risk factor. In general, however, mentally ill citizens are far more likely to be the victims of violence than its perpetrators.
Psychotic disorders: Police response. Officers who encounter a psychotic individual should observe a few basic rules of engagement. First, if possible, assess the nature of the subject’s psychotic state and overall behavior before approaching. This is to prevent either a lapse of precaution on the one hand, or an unnecessarily aggressive response on the other. Approach the subject as slowly and as non-threateningly as possible. If more than one officer is present, keep the sensory overload to a minimum by having only one officer speak at a time. Try to determine if the subject can be verbally engaged. Always speak and act slowly, firmly and deliberatively – remember the difference between authoritative (Sheriff Andy Taylor) and authoritarian (Deputy Barney Fife).
If the subject is willing to talk, encourage venting, but not ranting. If the subject expresses delusional ideas and beliefs, neither argue nor agree with the delusions. Through their painful life experiences, most schizophrenics have learned that other people don’t believe their delusional ideas, so pretending you do may only serve to further alienate and enrage an already disturbed psychotic subject. Conversely, it is highly unlikely that trying to “talk sense” into a delusional subject is going to make him suddenly see things more rationally. Instead, acknowledge the content of the delusion and try to ally yourself with the subject’s perspective and perception of the situation, while keeping the focus on present reality:
“Let me try to understand this. The terrorists have been sending you messages through your radio and cell phone, telling you of their plots to kill people, and you’re trying to fight them off and warn people, but nobody believes you. Do I have that right? That must be pretty scary and frustrating.”
Try to utilize active listening skills with the goal of calming the situation as much as possible. If physical restraint or arrest is required, utilize appropriate backup and safe takedown procedures. Remember that psychotic subjects can be very unpredictable – sitting and mumbling distractedly one moment, thrashing and kicking violently the next. If an arrest is not made, transport the subject to an appropriate medical or psychiatric receiving facility. Unfortunately, many mentally ill subjects who would best be served by a medical-psychiatric facility are nevertheless turned away from such facilities due to lack of funding or the facility’s refusal to accept intoxicated or potentially violent patients. In such cases, officers often have no choice but to arrest the subject on a misdemeanor charge in order to transport him to jail for his own and others’ safety.
Paranoid disorders: Police response. Paranoid schizophrenia presents a special challenge to nonviolent law enforcement intervention because the subject is already predisposed to mistrust everything you do or say. It is here that the concepts of de-escalation and preventive intervention are crucially important to keep the situation from escalating to violence.
Paranoid subjects are hypervigilant and suspicious. They are on high alert for the slightest hint of attack or treachery and tend to interpret every statement or action in a malevolent light. With such subjects, adopt an attitude of friendly and detached neutrality, of understanding without condescension. That is, commiserate with the distress the subject is obviously feeling, but don’t dismiss or talk down to him. This may sometimes be a challenge due to the natural tendency most people have to treat a “crazy person” like a child, which will only further infuriate a paranoid subject.
Wrong: “C’mon now, nobody’s after you, it’s just your imagination. Why don’t you be a good boy and come with us.”
Better: “I’m not sure I understand the whole situation, but I can see this is really upsetting you. Anything we can do to help?”
As with psychotic subjects in general, neither argue nor agree with the subject’s delusional content, but empathize with the distress the subject is expressing and show open-mindedness to the validity of the subject’s complaints. Remember that many paranoid delusions may build up around a kernel of reality, e.g. a worker may have truly been unfairly fired – not because of any delusional secret government plot to silence him, but because the small company was downsizing and they had to lay off somebody, so they picked the weird guy, betting that he wouldn’t have the mental wherewithal to pursue an antidiscrimination or unfair labor practices claim.
One thing to be especially alert for in the content of a paranoid subject’s verbalization is any risk of suicidality or violence, particularly if expressed toward specific targets (“Those yuppies can’t do this to me – I’m gonna teach that spoiled-brat boss a lesson!”). Again, it’s probably futile to try to correct the subject’s misinterpretations of reality, so keep your statements simple, concrete, and focused on the subject’s safety and well-being.
To this end, utilize appropriate proxemics (personal space) and body language, as well as verbal and nonverbal calming techniques [see the 04/18/08 column on “Patrol Psychology 101”]. Remember that paranoid subjects are particularly skittish about physical boundaries and proximity – they’re always on the alert for an attack. Unless and until physical restraint becomes necessary, keep a reasonable distance and inform the subject of what you are about to do: “Sir, I’m going to reach into my pocket to take out a pen and a pad, so I can write down some notes, okay? It’s just a pen and pad.” Then move slowly. Always use caution, however, because the subject may become panicked and turn violent in a flash.
When the decision to take down the subject has been made, do so quickly and purposefully. If the paranoid subject needs to be taken into custody, try to allow for some degree of self-respect to be preserved. Barking orders or playing rough as a “show of force” to cow the subject into submission is less likely to be effective with paranoid subjects and may only serve to further crank up the adrenalin spigot, heightening the risk of injury to all parties. Remember the principle of calm show of force from Part 1 of this series [05/12/08]: It’s usually safer for everyone concerned for 6 or 8 officers to calmly and safely restrain an agitated subject than for 2 or 3 officers to try and gator-wrassle a violently resisting, delusional citizen, so call for as much backup as needed for everyone’s safety.