A none happy thought in the world of mental health and law enforcement training

P bar Y Safety Consultants

A None Happy Thought in a Cruel World

and Policing

The majority of individuals that assault police/peace officers are under the influence of drugs or alcohol and/or have a

psychiatric disorder Often, officers perceive mental disturbance to be dangerous. Lacking the de-escalation skills necessary for

working with people with mental illness, officers may approach forcefully in order to resolve the situation quickly. This approach may escalate the situation to violence and injuries to the officer

and the person with a mental illness


Yes there can be outside additives in this new police/peace officer intervention


The whole truth

Psychiatrists who work with law enforcement professionals seek resources that examine how collaborative interventions between the disciplines can improve outcomes for citizens and officers during mental health crises. Improving Police Response to Persons With Mental Illness is one such resource.


Mental Illness Training in Law Enforcement

What it is, what it isn’t. How to deal with people

who have it


Law Enforcement Knows• Law Enforcement recognizes that while police/peace officers are

often engaged, the solution to mental health related issues requires a greater societal response. Street officers often reach out to community resources, such as nurses, doctors, family and friends, to bring individuals to the attention of health care providers.

• Law Enforcement Agencies believe this training is critically important, and requires all its police officers to have it regardless of rank or assignment.

Law Enforcements approach to training is to rely heavily on interactive scenario-based learning, as compared to a lecture approach.


In the LAW Enforcement WorldThe department mental health strategy focuses on several other key objectives, including:• strengthening our commitment to maintain an inclusive, healthy and

respectful workplace;• improving employee understanding of their respective roles in the

prevention, early detection and intervention of psychological health problems;

• where possible, reducing the presence and/or impact of psychological risks, and enhancing employees' capacity to manage remaining risks;

• ensuring that those in leadership positions within law enforcemnt are responsible and accountable for providing employees with available support services as early as possible; and

• measuring our psychological health and safety performance as part of the organization's annual management review process.


Law Enforcement Crisis Intervention Team Model

Dispatch Officer Citizen Event Disposition

Introductory TrainingIdentify CIT OfficersNew Procedures Volunteer

Patrol Role New Role Selection Specialized Training Maintain Safety Skills De-Escalation Skills New Procedures Lead Intervention De-escalation Skills Officer Discretion Receiving Facility

User Friendly


Working Assumptions

• Mental illness is not a crime.• Most people with mental illnesses are fully

functioning community members.• People with mental illnesses may be more

vulnerable to crime, abuse or injury.


Social Stress and Mental Illness

• Family problems• Interpersonal conflicts• Economic/financial difficulties• Role conflicts, role ambiguity, role overload

Some stress inducing conditions that can contribute to mental illness


And Other Significant Life Events:

• Loss of a loved one• Physical illness• Sexual Dysfunction• Loss of employment• Marriage• Birth of a child• Divorce• Retirement


Recognizing Mental Illness

• Mentally Ill individuals may be difficult to distinguish from any other person

• Can be quite intelligent, perceptive, and articulate

• Can be employed and maintain familiar relationships


Mental illnesses identified in childhood

• Mental Retardation• Autism• Oppositional Defiant Disorder• Conduct Disorder


Disorders of the Elderly

• Dementia includes:– Memory impairment– Deterioration of language skills– Impairment of motor functioning– Inability to process information


Dementia Features

• May underestimate risks – driving• May have severe mood swings• Delusions and hallucinations are common

– The most common are delusions concerning persecution

• Violent behavior and suicide may occur


Psychotic Disorders

• Disorganized thinking is the single most important feature of schizophrenia and other psychosis

• Answers to your questions may be somewhat related or completely unrelated

• Speech is usually disorganized as well• Catatonia

– Rigid– repetitive


Mental Illnesses are NOT:

• Developmental disabilities– Relate to intelligence and cognitive ability. Mental

illnesses are disorders of the brain that disrupt a person’s thinking, feeling and ability to relate to others.

• Psychopath or sociopath– Exhibits a callous disregard for the rights of others;

manipulates others for own gain; doesn’t see others as human.


Major Mental Illnesses are Biological Brain Disorders

• Schizophrenia• Bipolar Disorder• Major Depression• Obsessive-Compulsive Disorder• Anxiety/Panic Disorder


Are you talking there language

• Do you understand Deep Breathing Techniques

• Do you understand GROUNDING TECHNIQUES• DO YOU UNDERSTAND THEIR MEDS AND

WHAT IT DOES TO THEM IT IS NOT PRETTY SOME TIMES!


Never mind when we get here


Calm Breathing WORKS• What is “calm breathing”? Calm breathing (sometimes called “diaphragmatic

breathing”) is a technique that helps you slow down your breathing when feeling stressed or anxious. Newborn babies naturally breathe this way, and singers, wind instrument players, and yoga practitioners use this type of breathing.

Why is calm breathing important? • ♦ Our breathing changes when we are feeling anxious. We tend to take

short, quick, shallow breaths, or even hyperventilate; this is called “overbreathing”.

• ♦ It is a good idea to learn techniques for managing “overbreathing”, because this type of breathing can actually make you feel even more anxious (e.g., due to a racing heart, dizziness, or headaches)!

• ♦ Calm breathing is a great portable tool that you can use whenever you are feeling anxious. However, it does require some practice.



A few of Hundred that work



Schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder and panic disorder:

• Are the result of inadequate parenting.• Can be alleviated through the use of behavior

modification techniques.• Can be overcome by will and determination on

the part of the patient.• Are the result of organic brain diseases.• May be caused by insult to the brain, via virus or

allergen in utero or shortly after birth.• Can be treated effectively with medication that

targets the correct neurotransmitters.

NONO

NO

YESYES

YES


Schizophrenia is characterized by disordered thinking

• Positive Symptoms:– Confusion about what is real or imaginary– Preoccupation with religion– Belief in clairvoyance– Paranoia– Hallucinations– Heightened or dulled perceptions– Odd thinking and speaking processes– Racing thoughts or slowed down thoughts


• Negative symptoms of schizophrenia– Lack of friends– Passivity– Interacting in a mechanical way– Flat emotions– Decrease in facial expressions– Monotone speech– Lack of spontaneity– Difficulty in abstract thinking


Bipolar Disorder:dramatic mood swings

• Manic phase– Increased energy– Decreased need for sleep– Increased risk taking– Unrealistic belief in abilities– Increased talking and physical, social and sexual activity– Aggressive response to frustration– Racing, disconnected thoughts

– The depressed phase is similar to major depression


Major DepressionPersistent sad, anxious or empty mood

– Decreased energy, fatigue– Loss of interest in usual activities, including work and sex– Sleep disturbances (insomnia or oversleeping)– Appetite and weight changes– Hopelessness, pessimism– Guilt, helplessness, thoughts of death, suicide– Suicide attempts– Difficulty concentrating, making decisions– Hypochondria


Obsessive-Compulsive Disorder (OCD)

• Can’t stop some kind of behavior• Like a hiccup of the brain (a short circuit in the

basal ganglia)• Behavior repeated dozens of times a day


Anxiety/Panic Disorder

• Severe anxiety makes it impossible to act• Anxiety is out of proportion to the situation• Fear of doing routine tasks, like going to the

supermarket or riding a bicycle


Psychosis When a person experiences a psychotic

episode, all of the senses can be affected: sight, hearing, smell, touch.

It is something like an LSD trip without taking the drug; a chemical firestorm.

No one is in charge; central control is down.

It is terrifying, extremely confusing, real. Psychosis is a symptom, like a rash or

fever, and goes away with time or treatment.


TOP OF THE PAGE WORST


We see with our brains, not with our eyes. Our eyes send information to our brains

and our brains interpret the images.


Normal Psychotic

A person whose perceptions are normal

will see a flower and recognize it as a flower.

A person experiencing psychosis will often be unable to interpret what

his or her eyes see.


ANOSOGNOSIA32.1% are unaware they have an

illness25.3% are modestly unaware40.7% are awarePoor insight is a manifestation of the

illnessListenEmpathizePractice reflective listening


Interacting in crisis situationsDos and Don’ts

• DO– Remember that a person with mental illness has

the same rights to fair treatment and legal protection as anyone else.

– Continually assess the situation.– Maintain adequate space between you and the

subject.– Be calm


Do, continued

– Be helpful. In most cases people with mental illnesses will respond to questions concerning their basic needs. Ask “What would make you feel safer/calmer, etc?”

– Give firm, clear directions. The subject may already be confused and may have trouble making the simplest decision. Only one person should talk to the subject.


Do, continued

– Respond to apparent feelings, rather than content (“You look/sound scared.”)

– Respond to delusions and hallucinations by talking about the person’s feelings, not what he or she is saying (“That sounds frightening.” “I can see why you are angry.”)


DON’T

– Arrest an individual for behavioral manifestations of mental illness that are not criminal in nature.

– Join into behavior related to the person’s mental illness (e.g., agreeing/disagreeing with delusions/hallucinations).

– Stare at the subject. This may be interpreted as a threat.


Don’t, continued

– Confuse the subject. One person should interact with the subject. If a direction or command is given, follow through.

– Touch the subject. Although touching can be helpful to some people who are upset, for disturbed people with mental illnesses it may cause more fear and can lead to violence.


Don’t, continued

– Give multiple choices. Giving multiple choices increases the subject’s confusion.

– Whisper, joke or laugh. This increases the subject’s suspiciousness and the potential for violence.

– Deceive the subject. This increases fear and suspicion; the subject will likely discover the dishonesty and remember it.


Important questions to ask:

• Do you take any medications?• Have you taken your medication?• Do you want to hurt yourself?• Do you want to commit suicide?• Do you want to hurt someone?


Guidelines:dealing with persons with mental illness who are victims of crime or

abuse

• Approach a person with mental illness in a calm, non-threatening manner.– He or she may

• Be overwhelmed by delusions, paranoia or hallucinations

• Feel threatened by you or afraid of you.


• Determine whether a victim has a family member, guardian, or mental health service provider who helps them with daily living. Contact that person.

• Contact the local mental health crisis center immediately if an victim with mental illness is extremely agitated, uncommunicative, or displaying inappropriate emotional responses. He or she may be experiencing a psychiatric crisis.


• Ask victims with mental illness if they are taking any medications and, if so, the types prescribed.

• Make sure victims with mental illness have access to water, food and toilet facilities.


• Conduct your interview in a setting free of people or distractions. Only one person should conduct an interview.

• Keep your interview simple and brief. Be friendly and patient and offer encouragement.


• Be aware that people experiencing delusions, paranoia or hallucinations may still be able to provide details related to their situation.

• Allow people with mental illness time to calm down if they are acting excitedly and there is no immediate threat to anyone’s safety. Outbursts are usually of short duration.


• Break the speech pattern of people who talk nonstop by interrupting them with simple questions, such as their birth date or full name, to bring compulsive talking under control.

• Do not assume that those who are unresponsive to your statements cannot hear you.


• Understand that hallucinations are frighteningly real to people with mental illness.

• Acknowledge paranoia and delusions by empathizing with feelings but neither agree nor disagree with their statements.


• Continually assess a person’s emotional state for any indications that they may be a danger to themselves or others.

• Be honest. Getting caught in your well-intentioned deception will only increase their fear and suspicion of you.


Avoid the following conduct with people with mental illness:

• Circling, surrounding, closing in on, or standing too close.

• Sudden movements or rapid instructions and questioning.

• Whispering, joking or laughing in their presence.


Avoid, continued

• Direct, continuous eye contact, forced conversation or signs of impatience.

• Any touching.• Challenges to or agreement with their

delusions, paranoia or hallucinations.• Inappropriate language, such as “crazy,”

“psycho,” or “nuts.”


Using power of group therapy to foster a Peer Network

• Importance of regulated emotional expression in healthy relationships. “Admitting that I

can be vulnerable is tough but I need to lower my shield”

• Support and challenge from peers. “I know that

these guys have my back and that’s a good feeling”

• Process reactions of betrayal/mistrust. “I just wish

somebody would have asked me what I wanted”

• To re-establish positive connection to military identity. “I feel like I am

part of a unit again”

• OSI within the context of military careers. “There were

many good times, too, that I miss”

• Address retirement and abandonment reactions. “I would go

back in a heartbeat but I have to accept that it is over”


A Visual Representation of what see and what they could be seeing…


Psychotic Disorders

• Delusions – false belief that usually involve misinterpretation of perception or experience, despite contradictory evidence

• Delusions include– Persecutory– Referential- gestures, songs, books are specifically directed at them– Religious– Grandiose


Psychotic Disorders

• Hallucinations may occur in any sense• Auditory hallucinations are the most

common• Hallucinations shape, form and substance

that is real to the perceiver• Command hallucinations are the most

dangerous


Observable Symptoms• Statements that someone is trying to harm them• Wearing flamboyant clothing – or no clothing at all• Specific objects have special powers• Conversing with someone or something others

cannot see• Someone is the head of the CIA or CISIS and spying

on them


WHY oh why do you do it!

Many young people describe self-harm as a way of coping with feeling numb, or intense pain, distress or unbearable negative feelings, thoughts or memories. They are trying to change how they feel by replacing their emotional pain or pressure with physical pain. When they self-harm, they are not trying to kill themselves—they are trying to cope with their problems and pain. In fact, self-injury may be a way of helping themselves go on living. However, in the long-term, people who self-injure have a much higher risk of suicide, which is why it's so important to seek help.



Hell YES they may have weapons

Cutting is a way some people try to cope with the pain of strong emotions, intense pressure, or upsetting relationship problems. They may be dealing with feelings that seem too difficult to bear or bad situations they think can't change. Some people cut because they feel desperate for relief from bad feelings.



Some help but never forget to watch the hands

Here are some things that you can try to help a friend who cuts:• Talk about it. You've asked about the cuts and scratches

— and maybe your friend changed the subject. ...• Tell someone. ...• Help your friend find resources. ...• Help your friend find alternatives to cutting. ...• Acknowledge your friend's pain. ...• Be a good role model.


Symptoms of Depressed Mood• Argumentative, easily irritated (especially in

children)• Talks negatively about self, hopelessness• Sleeping excessively or not at all• Withdrawn, “down in the dumps” feeling• Fatigue or loss of energy nearly every day• Diminished ability to think or concentrate


Symptoms of Elevated Mood• Feelings of euphoria• Not needing to sleep or eat for days• Flight of ideas – thoughts are racing• Increased self esteem or grandiosity• Excessive involvement in pleasurable

activities that are risky – financially, sexually, physically


Bipolar

• Is a disorder that includes periods of mania and depression

• The cycles vary in duration– Months– Weeks– Days– Hours?


Anxiety Disorders

• Extreme sensations of nervousness, tension, apprehension, fear or anticipation of danger


Posttraumatic Stress Disorder

• Is the development of symptoms following exposure to a traumatic event– Soldiers, EMS, children victims, LEO

• Symptoms include– Avoidance of things that remind of the event– Increased arousal – hypervigilance, anger outbursts, startle response– Reexperiencing the event – hallucinations, dissociative flashbacks


Symptoms of Personality Disorders

• Self harm or risky behavior• Violating the rights of others• Difficulty with interpersonal relationships• Work or daily living is sometimes limited• Displays self-defeating behaviors• Has distorted view of the world

Exhibits patterns of:


Antisocial Personality Disorder

• A pervasive pattern of disregard and violation of the rights of others

• Deceit and manipulation are central features• Impulsive and irresponsible• Lack of remorse


Antisocial is Dangerous

• They are reckless with their and others safety• They are irritable and aggressive• They are much more likely to die by violent

means – suicide, accident, homicide


Borderline Personality Disorder

• A pervasive pattern of instability in interpersonal relationships

• Very impulsive – self damaging• Relationships may be love – hate• Poor self image


Borderlines are Dangerous

• Very common suicidal behavior• Self-mutilation• Intense anger, difficulty in controlling anger• Recurrent physical fights• Paranoid ideations


Psychiatric Medications

• Medications help a person manage the symptoms of their illness

• They are not a cure or magic bullet• Newer meds seem more effective in treating

psychosis and depression


Side Effects of Psychotropic Medications

• All medications carry the potential of a person developing side effects

• Side effects are the undesired effects of taking a medication and are different for different types of medication

• Can be uncomfortable, dehumanizing, and difficult to tolerate

• Some side effects are irreversible


Suicide is

• A form of behavior designed to deal with or solve a problem, a goal oriented coping method

• Sigmund Freud called it “murder turned inward”

• Or, the ultimate revenge…


Assessing Danger to Self• Are they talking about suicide?• Is there a suicide note?• Are there signs of hopelessness?• Is there a specific suicide plan?• Are there means at hand to harm self?• Has there been a previous attempt?• Is there evidence of self injury?


Suicide Intervention

• Listen• Be honest• Share your feelings• Ask the person very directly if they want to

commit suicide – Be graphic and direct (DSP)


You Must

• Be aware of the environment• Note the locations of entrances and exits and

the swing of doors• Determine the position of all involved persons• Survey site damage


Approaching the Subject• Use a triangular approach• Watch body language• Take charge• Move dangerous objects• Separate persons in conflict• Introduce yourself• Tell them why you are there


Remember to• Keep the subject’s hands in view• Remove influences that upset the subject• Do not violate personal space• Maneuver the person into a “safe area”• Avoid one-on-one physical contact• Maintain control


We Must

• Recognize that a mentally ill person in crisis may be overwhelmed by– Sensations– Thoughts– Frightening beliefs– hallucinations


Operational Safety Issues

• We must maintain our safety at all times• Maintain a position of safety – COVER• Always request back-up, never go it alone• Develop an initial intervention plan• Once back-up units arrive they must maintain

constant vigilance silently• Confine and isolate the situation


Always Remember to

• Be an active listener• Use your authority in a positive

manner

Leadership & Management

A none happy thought in the world of mental health and law enforcement training