Dealing with the non-violent mentally ill

[ST911]

Slide sidetrack, but likely topical. I am going to this class. Anyone been?

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[AMC]

I've had some experience working at a correctional facility for offenders with acute mental health issues. Many of the folks were at best marginally functional to the point that they were not even accountable for behavior normally addressed through the code of penal discipline (conduct rules and sanctions for misbehavior) for the incarcerated.

One of the startling things you see, if you pay attention, is how people cycle through symptoms and behaviors. It's very dramatic even for those who were on highly regulated chemical therapy. Once those folks get to the street they often drop or have less access to the med's that allow them to function "best." When that happens their behavior cycles exponentially more rapidly.

The best advice I've got (due to time constraints) is to ensure that you're providing clear step by step instructions or question rather than what I'd poorly term, "conjuctive" or complex instuctions. Ask simple questions and break things down into small manageable concepts -without condescending, and then validate their understanding of what you said.

One tool that's a big help is Motivational Interviewing, a technique which differs widely from forensic interviewing. It's worth a study for anyone dealing with the public in difficult situations or when you're attempting to modify behavior.

Saw this class in the Force Science Newsletter. I'm interested to hear your take when you're done! This is the missing element in most De-Escalation programs... recognizing when it's possible to de-escalate, and when immediate action is required.

[Rex G]

Now I know for a fact she's been screamed and cursed at by other first responders. Here's the point of where I'm going with this. It's not her fault. Some chemical or wiring in your brain could have come out a little wrong and you'd be the same as her. Don't forget that there but by the Grace of God go you. Being an asshole isn't going to help, and you're making it harder for the next cop/EMT/fireman who deals with her...and you know they are going to.

This. Not only could any of us have been wired differently, and been like her, some of us are wired with the potential to be “her,” and just don’t yet know it. Some will develop the issues with age and time, and some will have some of the “wiring” already in place, with something like a car crash, causing a brain injury, being what pushes us over the edge.

I am no SME, but was one of Houston* PD’s first CIT-trained officers, stayed up-to-date with the yearly refreshers, and worked nearly 34 years of night shift, in an area with one of the highest concentrations of mental health consumers, between the Texas Medical Center, and the CBD.

I understand “compassion fatigue.” Being the “camera unit” for family violence injuries, and a CIT officer, was a trying experience. (My wife’s sister, the widow of a Viet Nam combat vet, tells me I am a walking case of PTSD.)

*Houston PD did not invent CIT, but was an early adopter of CIT, and the HPD academy became quite a hub of CIT training for other PDs.

[ubervic]

I hold a bachelors in psychology. Many people don't understand, or believe, that individuals with psychosis and other acute mental illnesses often hallucinate very vividly. In their mind's eye, they are truly seeing/feeling/experiencing that which they state. Good on those who have the insight, skill and courage to 'talk them down' in a way that they can actually relate to and work with.

[olstyn]

I'll post this weekend with some info.

I'm a psych nurse in a locked unit.

I'm in healthcare IT, and I remember replacing some PCs in those locked mental health units back before I moved into a more "real" position. I couldn't help but think that the folks working in those units were due for sainthood any second, and also that the burnout rate must be incredibly high working there. Thank you for taking care of those who can't take care of themselves.

[fastreb]

After I went to work for Memphis PD, I became a CIT officer and did it for 5 years. One of the biggest things I found that helped you make a connection with the consumer was being honest and, as others have said, not buying into the delusions of the mental health consumer. They also taught us that if the consumer is shouting or loud, remain calm and start lowering your voice. The technique really does work and I've used it many times. Another thing I learned was that in many cases, the consumer stops using their meds because they don't like some of the side-effects. So, most times I would ask the consumer how they felt after they took the meds and include that information in the paperwork if they had to be emergency committed. I figured the doctor could probably use the information to possibly adjust the meds to something the consumer might be able to physically handle better, which would hopefully get the consumer to take it regularly. For others, especially if they had bi-polar disorder, the consumer would tell me the meds made them feel like they were moving in slow-motion, both physically and mentally. As for how much time is not enough or too much, there is no yardstick I know of. Each encounter is different, even if it's the same consumer you've dealt with 100 times before. All you can really do is remember what others have already said....treat the consumer like you would want your family member to be treated, or even you yourself.

[03RN]

Sorry, it's coming. Our 1st born surprised us and came 5 weeks early. I'm taking the week off so should find the time and the right words.

[03RN]

Some things I've discovered. Some was taught, some was learned through interactions. I can not say that all of my methods will work for everyone. Some I've had to develop for myself because of my look and demeanor.

There are different diagnoses that require a different approach. Not knowing the person's diagnoses from medical records you need to learn how to tell them apart.

Bipolar, schizophrenia, schizoaffective, drug induced psychosis, behavioral are probably what will cause you as law enforcement problems. Another one might be a boarder line who displays self injurous behavior (the most staff intensive patients we get).

I think bipolar patients in mania might be the most dangerous. For the first couple days they can be violent. I've been punched, attacked, spit on, and been verbally abusive to staff and peers on the unit. A lot of them refuse medications.

They can be unpredictable but do tend to respond to clear, firm rules. On meds they usually live productive normal lives. Off meds they can be very unpredictable. If they are not following instructions it might be because you are trying to be a little to authoritarian with them and they are posturing.

They normally can't be reasoned with, depending on how long they have been without restful sleep.

That is not all bipolar patients. I said I think they might be the most dangerous but that is a very small percentile. I know some that have been off meds for months and need help but are not unreasonable and actually can be pleasantly. Just staff intensive when you're trying to get work done.

Some of our patients are brought to us after cops respond to calls of unruly and disorganized behavior in public. If it's to the point where cops are called they are generally physically restrained by them on the way to the ER. Sometimes tackled. They aren't violent per se but they do not listen to instructions by cops and like I said, posture.

With patients with bipolar d/o I'll lower my voice and speak softer. It forces them to slow down and listen. When they start ramping it up, I'll sometimes sit down on the ground to talk.

Sometimes they are to far gone and need restraints and meds. They can not all be talked down. After a few days and some meds they will apologise and be great patients.

Sorry if this is disjointed. I'm on my phone so my screen is cut while I type.

[BehindBlueI's]

Some things I've discovered. Some was taught, some was learned through interactions. I can not say that all of my methods will work for everyone. Some I've had to develop for myself because of my look and demeanor.

There are different diagnoses that require a different approach. Not knowing the person's diagnoses from medical records you need to learn how to tell them apart.

Bipolar, schizophrenia, schizoaffective, drug induced psychosis, behavioral are probably what will cause you as law enforcement problems. Another one might be a boarder line who displays self injurous behavior (the most staff intensive patients we get).

I think bipolar patients in mania might be the most dangerous. For the first couple days they can be violent. I've been punched, attacked, spit on, and been verbally abusive to staff and peers on the unit. A lot of them refuse medications.

They can be unpredictable but do tend to respond to clear, firm rules. On meds they usually live productive normal lives. Off meds they can be very unpredictable. If they are not following instructions it might be because you are trying to be a little to authoritarian with them and they are posturing.

They normally can't be reasoned with, depending on how long they have been without restful sleep.

That is not all bipolar patients. I said I think they might be the most dangerous but that is a very small percentile. I know some that have been off meds for months and need help but are not unreasonable and actually can be pleasantly. Just staff intensive when you're trying to get work done.

Some of our patients are brought to us after cops respond to calls of unruly and disorganized behavior in public. If it's to the point where cops are called they are generally physically restrained by them on the way to the ER. Sometimes tackled. They aren't violent per se but they do not listen to instructions by cops and like I said, posture.

With patients with bipolar d/o I'll lower my voice and speak softer. It forces them to slow down and listen. When they start ramping it up, I'll sometimes sit down on the ground to talk.

Sometimes they are to far gone and need restraints and meds. They can not all be talked down. After a few days and some meds they will apologise and be great patients.

Sorry if this is disjointed. I'm on my phone so my screen is cut while I type.

Not disjointed, and I hope you continue to add more as you can. Congratulations on the newly expanded family, and thanks for taking time away from all your new responsibilities to help us out.

The only thing I'd say is difficult to translate over to LE is sitting on the ground. I will squat if they are seated (which sucks because of my knee, but whatchagonnado?) and make sure I've got enough room to stand up and move back if they start to stand or move where they can lunge.

[03RN]

Agreed but it's very hard to deescalate a person if you look like you are ready to throw down. I try not intimidate patients. I'm 5'11, muscular, short hair etc. It's hard to convince some patients I'm not there to hurt them. Sitting is a sign that I'm there to help and calms them down. I'm also athletic enough with almost 30 years of HTH experience to be able to assess the patient and the situation.

I don't really want to make this a post about me but it might help Leo see where I'm coming from. I'm a Marine, wrestled in the IL state championships in HS, a couple black belts, powerlifting trophy's, I've trained in Japan and Thailand. I've bounced for the last ten years PT and pretty confident in what I can and can't do.
So trying to convince patients I am a nurse and there to talk to them isn't always easy. I need to adjust my posture and facial expressions to the situation. If it's possible to deescalate a situation I do not escalate it by ratcheting up the intensity. I need to bring it down. It is risky to sit but it's calculated and has always worked. I do not always do it though. Sometimes patients are past that and they are restrained. I work overnight with a small staff and hate restraining patients and do everything to avoid it.

Honestly, if I was a cop I'd just restrain them and bring them to the ER.