The Knee is Connected To The Thigh Bone:The Complex Connections between Law Enforcement and Mental Health

Darin Nelson LIMHP, LADC, IADCDirector of Crisis Response Services

Heartland Family Service302 American Parkway, Papillion, NE. 68046

Phone: 402-552-7079Fax: 402-339-4358E-Mail: dnelson@heartlandfamilyservice.orgWebsite: heartlandfamilyservice.org

“Suicide is man's way of telling God, 'You can't fire me - I quit!” ― Bill Maher

Ryan’s Story

“Living is much harder than dying”

• Identify key concepts of MH/LE interactions.• Understand individual and community

reactions• Apply individual and LE intervention

strategies.

Session Objectives

Susan’s Story

“They are coming to get me”

Noun:

Ensuring obedience to the laws; enforcement - the act of enforcing; ensuring observance of or obedience to

law, jurisprudence - the collection of rules imposed by authority; "civilization presupposes respect for the law"; "the great problem for jurisprudence to allow freedom while enforcing order"

Law Enforcement Definition

A mental health emergency is when an individual's mental or emotional condition results in behavior that constitutes an imminent danger to that individual or to another person. Emergencies require immediate attention. The following are indications of a mental health emergency: • (1) suicidal intentions, plans, or attempts; • (2) homicidal intentions, plans, or actions; • (3) loss of contact with reality, which may include hallucinations,

delusions, or extremely abnormal behavior causing a campus disturbance or disruption;

• (4) disorientation, extreme confusion, unresponsiveness, uncontrolled behavior, extremely irrational or incoherent speech.

Mental Health Emergency Definition

How do two diametrically opposed professions come together and work toward the best interest of an individual?

THE FINE LINE

In Omaha, a Crisis Intervention Team (CIT) model was developed and adopted as a cooperative community partnership involving law enforcement agencies, mental health service providers, mental health consumers, family members, and community funders.

Through participation in this program, CIT police officers learn to recognize common forms of mental illness and to utilize the most effective means of communicating with people undergoing crisis. The officers are trained to de-escalate the individuals in crisis and allow the consumer to participate in the decision-making regarding their treatment.

CIT in the Omaha Area

CIT officers must successfully complete 40 hours of training to become certified. Training is provided by consumers, family members, mental health providers, law enforcement, and county attorneys and involves not only classroom exercises but also panel presentations, site visits, and scenario based training. Participation on the CIT team is voluntary and officers must apply to be chosen.

CIT in the Omaha Area

Since March of 2006 participants from the Omaha Police Department, Douglas County Sheriff, County Corrections, 911 Dispatch, Boys Town Police Department, Papillion Police Department, Bellevue Police Department, and Plattsmouth Police Department have been trained and certified in the CIT model. Citizens in need of assistance can request that a CIT trained officer be dispatched when calling any of the departments listed above. CIT officers are easily identifiable to members of the mental health community as they wear a distinctive CIT pin on the right lapel of their uniform.

CIT in the Omaha Area

• Baseline Statistics• Purpose• Funding• Philosophy• Goals• Infrastructure

Our Story - History

Integrating mental health staff with Law Enforcement personnel will optimize access to appropriate resources and reduce stigma for those seeking treatment, as well as reduce unnecessary incarcerations and Emergency Protective Custody situations. The service allows for complimentary utilization of the strengths of mental health, law enforcement and/or medical professionals.

Philosophy

Alegent

Multiple Agencies in the Omaha Area

• In the last 4.5 years, over 2,000 individuals have been assessed by the MH/LE teams.• 95% did not have to be hospitalized.

• PRIOR TO THE PROGRAM, 100% would have been hospitalized to “Liability” concerns

Brief Statistics

How LE and MH teams combine skills

The Journey

• An officer doubts the need for an EPC.• An officer thinks there are alternatives to EPC,

but is unfamiliar with them.• The individual does not qualify for an EPC,

but needs assistance.• An officer wants a consultation on a possible

EPC.

Common Utilization of Crisis Response Teams

• Thoughts, feelings, dreams, and memories associated with the event

• Grief and Sadness• Fear and Anxiety• Frustration, Anger, and Guilt

Individual Reactions to Crisis

• Increase in preparedness activities• Resurgence of media and political attention• Community solidarity or discord

Community reactions to crisis

“getting there is the first step” – Lt. Chris Whitted, Papillion Police Dept.

• Exigent Call

• Normal Call• FOCUS – Timely/Safe Response

Law Enforcement Call Response

• Mobile crisis response to scene in the community.

• FOCUS – Timely Safe Response

Mental Health Call Response

• Can I get in• Are there any weapons• Is individual alone or not• Is their agitation or not• Any suicide by cop• Who are the players involved• Where is the best place to talk• FOCUS – Community Safety

Law Enforcement Initial Assessment

Mental health assessment is a process that involves the integration of information from multiple sources, such as personal and medical history, description of current symptoms and problems, and sometimes other information such as psychological test results. All mental health professionals do some level of assessment when providing services to clients, and may use checklists or inventories to assess traits or symptoms.

Mental Health Initial Assessment

The interview during the first meeting with a mental health professional is structured to gain information used for assessment. Assessment is also an ongoing process. The aims of assessment are to provide a diagnosis, to determine an individual's level of function or disability, to help plan and direct the appropriate services, and to measure the outcome of the services or treatment intervention.FOCUS – Individual safety

Mental Health Initial Assessment

• Behavior• Suicide attempt in progress• Weapons involved • Statement of suicide to dispatcher.

• FOCUS – Community Safety

Law Enforcement – Processing Situation

• Behavior• Mental Health• Suicide/Homicide Ideation• Risk Factors• Protective Factors

FOCUS – Needs of person in crisis

Mental Health – Processing Situation

• Refusal to speak• Drugs/Alcohol involved• Depression verging on suicidal• Bizarre behavior • Statements of family regarding unseen

behavior• Others

“Fence Walkers”

• Conducting the Interview• History: personal & familial at risk behavior• Predisposing vulnerabilities • Depression; substance use; other mental health diagnoses

• Any means & plans the client may have about carrying out the risk behavior

• Controls: internal & external that are stopping the client from undertaking the risk behavior

• Precipitating factors • Conflict; break-up of relationship; health crisis

Performing the Assessment

• Observations during the Interview:• Level of anxiety; desperation; despair; sense of

hopelessness; contact with reality• Appearance & behavior (neat/dirty, attitude

toward officer, nervous mannerisms)• Thought Content (preoccupations, delusions,

suspicions, paranoia, nonsensical thought)• Manner of speech (easy, reluctant, silent,

confused, pressured)

Performing the Assessment (cont’d)

• Observations (cont’d):• Perceptual abnormalities (visual, mental, tactile,

auditory or olfactory hallucinations; depersonalized or perceptual realities)

• Affect-prevailing emotional tone (happiness, sadness, anxiety, flat affect, suspicion)

• Concentration• Cognitive-intellectual functions (alert, drowsy,

confused)

Performing the Assessment (cont’d)

• Protective Factors (or contraindications)• Coping skills; hopeful attitude toward the future; strong

social support or connectedness• Focusing is the most essential skill & technique at this

stage, while allowing the client to express the overwhelming flood of emotions.• Focusing technique can elicit more coherent information for

assessment, as well as, help the client pull themselves together cognitively and emotionally.

• A focused interview can serve as a instrument of both assessment and intervention.

Performing the Assessment (cont’d)

“If I had no sense of humor, I would long ago have committed suicide.” ― Mahatma Gandhi

Sarpy County Nebraska: – From 2006 through 2008 there was a 400%

increase in Emergency Protective Custody.– All were hospitalized.

This was the result of very involved policing with concern for obtaining assistance for citizens in

need.

Gather Baseline Statistics

• Assist Law Enforcement in assessing the needs of a citizen immediately following/during crisis event.

• Assist in supporting needs of the citizen and Law Enforcement immediately following crisis event.

• Assist in providing crucial referral information & 24 hour follow up support to the citizen.

Define Program Purpose

• To respond to individuals in their community, and provide immediate crisis response.

• To utilize the least intrusive, most effective intervention to provide immediate support, information and referrals, and facilitate problem-solving to assist in the alleviation of a mental health or psychiatric crisis.

Goals of Crisis Response Teams

• Law Enforcement Engagement• External Training• Internal Training• Challenges• Successes

Program Implementation

• Law Enforcement Professionals provide up to 1/3 of all emergency mental health referrals.

• They interact with more persons with mental illness than any other occupational group outside of the mental health field.

• They are often the first to respond to a mentally ill person in crisis, yet, in general, their training in mental illness is limited.

Engaging Law Enforcement

Address their concerns to ensure buy-in. • Liability regarding safety of person in crisis.• Response time – time saved by Crisis

Response Team. HFS Crisis Response Teams provide 4 hour

trainings to all Law Enforcement Agencies in the counties served.

Law Enforcement: The Biggest Stakeholder

• Trainings offered to referring agencies to provide general information about working with those with mental illness.

• Basic assessment skills are taught to recognize warning signs of suicide.

• Dispel myths and familiarize front line workers with issues surrounding crisis intervention and mental illness.

External Training

• Define Crisis and Crisis Theory• Define Crisis Intervention• Assessment• Evaluating Risk• Suicide Assessment

Program Assessments

• A family member, friend or other concerned person calls the police for help during a psychiatric emergency.

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

• Police Officers encounter a person with mental illness behaving inappropriately in public.

• Citizens call the police because they feel threatened by the unusual behavior or the mere presence of a person with mental illness.

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

Common Situations Encountered

The exact nature of the intervention will depend on the client’s pre-existing strengths & supports.

• Affective: • Expression and management of feelings

involving techniques of ventilation, psychological support and emotional catharsis.

• Cognitive:• Helping the client understand the connections

between the stressor event and their response.

Crisis Intervention Approaches

• Cognitive (cont’d):• Techniques include clarifying the problem,

identifying and isolating the factors involved, helping the client gain an intellectual understanding of the crisis.

• Also involves giving information, discussing alternative coping strategies and changing perceptions.

Crisis Intervention Approaches

• Environmental Modification:• Pulling together needed external,

environmental resources (either familial or formal helping agencies).

Any and all 3 approaches may be used at any time, depending where the client is emotionally

and cognitively.

Crisis Intervention Approaches

• Components of Suicide Assessment:• Appreciate the complexity of suicide – multiple

contributing factors.• Conduct a thorough psychiatric examination,

identifying risk & protective factors and distinguishing between risk factors that can be modified and those that cannot.

• Ask directly about suicide.

Suicide Assessment

• Protective Factors – Factors that make it less likely that someone will commit suicide.• Getting help for mental, physical and substance

abuse disorders – especially depression• Restricted access to highly lethal methods of

suicide – especially firearms• Family and community support• An established relationship with a doctor, clergy,

teacher, counselor, or other professional who can help

Protection Against SuicideGreen Light…Good to Go!

• Psychiatric Disorders• Past History of Attempted Suicide• Genetic Predisposition• Impulsivity• Demographics:

• Sex: Males are three to five times more likely to commit suicide than female.

• Age: Elderly Caucasian males have the highest suicide rates.

Suicide Risk FactorsYellow Light…Proceed with Caution

• Talking, reading, or writing about suicide or death.• Talking about feeling worthless and helpless.• Saying things like, “I’m going kill myself,” “I wish I

was dead,” or “I shouldn’t have been born.”• Visiting or calling people to say goodbye.• Giving things away or returning borrowed items.• Self destructive or reckless behavior.• Significant change in behavior.

Suicide Warning SignsRed Light…Stop the Suicide!

• Assessing clients under unusual circumstances (i.e. in jail, with officer in room, on the side of highway).

• Changing Police Procedures.• Criminal Justice Mindset vs. Therapeutic Intervention.• Dangerousness of Scene – when assessing and

responding to non-law enforcement agencies.• Educating Law Enforcement about those appropriate for

Emergency Protective Custody due to mental health deterioration.

Challenges Faced by Crisis Response Team

Heartland Family Service Crisis Response Teams respond to:• Law Enforcement at crisis scene• Casinos • County Jails• Homeless Shelters• Heartland Family Service• Juvenile Justice/Detention Center• Juvenile Court Services• Public Schools• Residential Correctional Facility

Challenges of Growth

• The Program began in 1 county and is now serving 3 counties.

• The Program originally employed 1 FTE and 6 on-call staff. Currently there are 3 FTE and 11 on-call staff.

• The program has expanded from 5 law enforcement agencies at the beginning to now responding to 11 Law Enforcement agencies, 2 juvenile detention centers, 3 county jails, 131 schools, and 1 post-prison release residential center.

Successes

• In June 2012, the Crisis Response Team responded to its 2000th assessment call.

• 95% of the individuals that were assessed were found to not to be in need of hospitalization.

• The estimated cost of serving those 95% of people in a minimum 3-day forced hospitalization would be 6 million dollars. This is a substantial savings to the county and state. It also is a reduction of further trauma to the person in crisis.

Successes (cont’d)

• Increased safety to the person in crisis.• Decreased trauma to the person in crisis.• Increased information available to Law

Enforcement to make decision regarding EPC’s.

• Decreased amount of money the county and state are paying for hospitalizations.

Why the Program Grew so Quickly

Questions & Answers

Thank You!