Book excerpt: Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry

The faulty mental health system has forced law enforcement personnel to do the work that mental health professionals stopped doing


When hospitals release seriously mentally ill patients too soon without outpatient follow-up, the patients can end up homeless, jailed, harming others, or even dead. When patients are deemed suitable for inpatient care, they can languish for weeks in hospital emergency departments before placements become available. The following is excerpted from Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry by Lynn Nanos, which opens a dialogue with anyone interested in improving the system of care for the seriously mentally ill population. 

Chapter 9: Police

I’m at a Department of Mental Health (DMH)-funded residential program and conclude that an involuntary transfer to the hospital via Section 12 is needed for Jessica, who is forty-two years old. Her delusion is that feces is in food, which prompts her to avoid eating. She cannot listen to staff members encouraging her to eat her lunch. She cannot concentrate and is highly distracted by her hallucinations instead. I cannot gather what exactly these involve because she is guarded. The staff members tell me that she has lost thirty-eight pounds in just six weeks. She emphasizes, “Feces is in there. They won’t remove it!” She cannot elaborate on how she came to conclude this.

The ambulance crew asks us what her current medications are. Almost in unison, the residential staff members and I state that she has no prescribed medication because she has not wanted any for months. Despite our attempts to persuade her to cooperate with the ambulance crew, she won’t budge. She yells, “I’m fine. I don’t need to go to the hospital!” as she becomes restless before slumping on the couch.

"Breakdown" opens a dialogue with anyone interested in improving the system of care for the seriously mentally ill population.
"Breakdown" opens a dialogue with anyone interested in improving the system of care for the seriously mentally ill population.

Four police officers arrive to assist. I tell them why Jessica needs to go to the hospital. Two of them approach Jessica and introduce themselves, expressing an interest to help. Their attempts to persuade her to go to the hospital don’t work. As the officer glances and points at me, he highlights, “They said you’re delusional. There’s no feces in your food. You have to go to the hospital.” Jessica suddenly picks up a nearby ceramic vase and attempts to throw it at me. The officers quickly immobilize her using their arms. They handcuff her as she curses and screams.

If the officer had known that delusional patients often lack insight, perhaps he would not have chosen such a brutally honest approach. He might not have disputed her belief that the food is contaminated. Jessica’s lack of insight is impenetrable. The officer is not part of a specialized Crisis Intervention Team (CIT).

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CIT police officers have completed forty hours of mental health training. This teaches the officers how to verbally de-escalate potentially volatile encounters with mentally ill people. The main aim of the CIT is to help people avoid being arrested and instead access mental health treatment.

Traditional police training might increase the risk of fatalities with its push for rapid solutions. [1] This approach might not allow sufficient opportunity for officers to listen to people in crisis. If an officer’s approach is too authoritarian, the person in crisis might react impulsively out of increased fear. Empathizing with him is more likely to result in more trust, less defensiveness, a decrease in fear, and a willingness to collaborate cooperatively.

The first CIT in the United States was formed in Memphis, Tennessee, in 1988 as a reaction to a tragedy in that city. [2] On September 24, 1987, a relative of Joseph DeWayne Robinson called the Memphis police because Joseph, twenty-seven years old, was posing a danger to himself and others. It was believed that Joseph had paranoid schizophrenia. Police officers found him holding a large knife. He threatened to harm others seriously and cut himself. Failing to cooperate with the officers’ demands to let go of the knife, the man charged the officers. Police officers believed their lives were in danger. A police officer shot Joseph repeatedly, killing him. [3] This event provoked outrage and generated a movement toward the CIT model.

Suicidal threats, regardless of whether psychosis is involved, often involve police confrontations. The Boston Globe reviewed police reports involving suicidal people in Massachusetts and the District Attorney’s reports of fatal shootings. In 65 percent of the shootings involving apparent mental illness, the weapon was a sharp object, such as a knife. In 13 percent of the shootings, police shot people holding firearms. They found that 90 percent of the people who were shot by police did not drop their weapons when ordered to do so. [1] The Boston Globe found that many of these confrontations with police could have been prevented. For instance, some of these cases involved premature discharges from inpatient psychiatric units or a lack of enough support for mentally ill people. [1]

The faulty mental health system has forced law enforcement personnel to do the work that mental health professionals stopped doing. Law enforcement officers interact so frequently with people in psychiatric crisis that they can authorize Section 12s. For example, a young adult being prescribed antipsychotic medication refuses to take his medication and consequently threatens to seriously harm the family with whom he resides because he believes that they are plotting to kill him. His mother calls the mobile emergency services team to request that a clinician come to their home to evaluate him. But if he is not agreeable to this, no clinician can see him at home. Moments later, he pulls a knife on his mother and threatens to harm her. She successfully persuades him to drop the knife and calls the police for help.

Familiarity with such cases is ingrained in officers. As expected, all police officers are required to have a basic knowledge of mental illness. But most officers are not part of CITs. They are not sufficiently trained in managing the breadth of mental illness that exists outside of secure settings. Most police departments in Massachusetts do not have CIT programs due to funding limits and shift coverage.

Many of the CIT programs that do exist in Massachusetts are limited, involving too few CIT-trained officers. [1] The Memphis CIT recommends that 20 to 25 percent of police officers become CIT-trained. [4] According to The Boston Globe, only about 20 percent of Massachusetts police departments provide major mental health crisis training to officers or obtain help from social workers for mental health cases. [1] Not nearly enough officers have gained the skills required to identify subtle signs of mental illness and to placate mentally ill people who might be at risk of becoming violent. Cooperation with treatment recommendations for this population is more likely to occur when police officers are proficient in managing interactions with these people.

References

1. Globe Spotlight Team, Jenna Russell, et al. The desperate and the dead: Police confrontation. The Boston Globe, July 6, 2016.

2. Bayne MC. Furor sparks call for crisis team. Metro: The Commercial Appeal, September 30, 1987, B1.

3. Codispoti A. Dealing with mentally ill a police focus: Roanoke police officers are trained in intervention techniques for dealing with the mentally ill. Roanoke Times, July 19, 2009.

4. Dupont R, Cochran S, Pillsbury S. Crisis intervention team core elements. Department of Criminology and Criminal Justice—CIT Center, 2007. University of Memphis—School of Urban Affairs and Public Policy. 

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