Responding to Individuals with Mental Illness.

Two officers respond to a disturbance call. At the scene, a woman informs the officers that her brother is behaving violently, threatening family members, and has a history of mental illness. What should the officers do to resolve the situation?

With the cutback in public funding for mental health facilities and services, families and communities find themselves seeking alternatives for handling uncooperative or violent individuals who are mentally ill. One common method involves using local law enforcement agencies. However, police officers receive training in enforcing the law, not necessarily in interacting with individuals with mental illness.

All too often, law enforcement officers find it difficult to determine whether they are witnessing an individual's mental illness manifesting itself or some type of unlawful behavior. In such cases, officers generally lean toward their law enforcement training and follow procedures for interacting with criminals. This can lead to citizen complaints and lawsuits when it turns out that subjects actually have been diagnosed with bipolar disorder, schizophrenia, paranoia, or other mental diseases that made them disoriented, resistant, or violent toward police officers. Fortunately, alternative methods of dealing with individuals with such illnesses exist.

ONE DEPARTMENT'S SOLUTION

In 1983, the city of New Orleans, Louisiana, its police department, and the state's mental health services established a mobile crisis service. The supervisor of the community's crisis hotline observed that many callers requested intervention in their situations. However, the callers did not want to involve the police because they felt that the situation was not a law enforcement matter. They also did not want emergency medical personnel to respond because the situation was not a physical medical emergency. Therefore, the supervisor developed the idea of having trained volunteers respond to psychiatric emergencies to provide crisis intervention and mental health assessments. Since that time, every day between noon and midnight, specially trained volunteers from the local area provide crisis intervention and mental health evaluations at the scene of psychiatric emergencies to which the police department has responded.

Defining the Volunteer's Role

Although the crisis service is attached to the Special Operations Tactical Division of the New Orleans Police Department, the volunteers are not sworn law enforcement officers. Instead, they have a limited commission that empowers them to place individuals into appropriate mental health facilities when such action appears appropriate and when such individuals are unable to seek help themselves due to their mental state. This limited commission also gives the volunteers broader powers than emergency medical services (EMS) personnel. For example, unlike EMS personnel, who must obtain an individual's consent, crisis service volunteers can compel individuals to mental health facilities based on their observations at the scene. The volunteers base their decisions on their own positive responses to any one of these three questions:

1) Are the individuals a potential harm to themselves?

2) Do they pose a threat to others?

3) Are they gravely disabled either in judgment or because of substance abuse?

Even when a disturbance does not meet these criteria, the crisis service volunteers can have a significant impact. For example, the volunteers often can convince subjects who exhibit a less violent, milder form of mental illness to seek help from outpatient mental health services, which may prove more appropriate to their needs. Also, by directing such individuals to temporary outpatient services rather than admitting them to mental health medical facilities, the volunteers help reduce the burden on limited public resources.

Training the Volunteers

The average volunteer ranges in age from 30 to 40 and holds a master's degree. Many do not work in the field of mental health but come from a variety of professions, including teaching, law, medicine, and various trade and service occupations. Regardless of their regular employment, all volunteers receive nearly 3 months of classroom instruction, consisting of police procedures, report writing, interacting with individuals who are mentally ill, basic first aid, CPR, nonviolent physical crisis intervention, and safe-driving training. In addition to the classroom instruction, all volunteers must participate in a ride-along field training program for seven shifts.

Funding the Service

The crisis service receives funds from both the New Orleans Police Department and the Louisiana Office of Mental Health. The state currently provides $150,000 annually for the purchase of emergency vehicles, office supplies, and a full-time staff, as well as for volunteer recruitment and incentives. The police department provides office space, vehicle fuel and maintenance, insurance, and the services of a police sergeant to command the unit. The insurance coverage for the volunteers and vehicles stems from other volunteer programs of the city government. Interestingly, in the 16-year history of the service, volunteers have sustained injuries in only two cases.

Measuring the Benefits

During its operational hours, the crisis service can respond to about 60 percent of all police calls for service involving subjects with mental illness who have become violent. Because the service currently has only one response unit, police officers handle the remainder of such calls that the crisis service cannot cover. In over 85 percent of the calls that the service can answer, volunteers successfully intervene and defuse the subjects by the time they reach the receiving mental health facility. These successful interventions include individuals with Alzheimer's disease, dementia, alcoholism and other substance addictions, bipolar disorder, schizophrenia, paranoia, suicidal and homicidal thoughts, depression, and posttraumatic stress disorder.

The crisis service has allowed police officers to concentrate on law enforcement duties, relieved the prison system by diverting subjects to appropriate mental health facilities, and saved the city of New Orleans approximately $300,000 per year. Further, this intervention has reduced the number of lawsuits filed against police by individuals who are mentally ill or their advocates.

Individuals with mental illness also benefit from this system. Often, subjects recognize the volunteers. This usually helps these individuals realize that they will receive the care they need as opposed to facing criminal proceedings. In many cases, individuals with mental illness are relieved to see the crisis service arrive and, with the assistance of the trained volunteers, can calm themselves and avoid a potentially dangerous situation. For example, the successful resolution of the scenario at the beginning of this article may illustrate best the benefits that the crisis service can bring to all involved parties. After the trained volunteers arrived at the scene, they performed a mental health status evaluation of the man, while the officers maintained everyone's safety. The volunteers observed that the man was acting paranoid, experiencing audio hallucinations, and becoming progressively physically agitated. In talking with the man, they found that he did not know the time, date, his name, and where he lived. He changed subjects and ideas rapidly, forgot questions posed to him, and told the volunteers that he felt angry. Finally, in a lucid moment, the man admitted that he had stopped taking the medications prescribed by his doctor to control his mental illness. Based on these observations, the volunteers determined that without his medications, the man was gravely disabled and posed a danger to himself and others. Thinking that the officers wanted to arrest him, the man became more agitated. The volunteers explained that he was not under arrest but in need of help. They told him that they would take him to a hospital for a complete evaluation. Once he understood that he was not going to jail, he visibly calmed down. The volunteers transported him to the hospital, and the officers returned to their law enforcement duties.

Mental health professionals benefit from the crisis service's existence, as well. When volunteers transport subjects to mental health facilities, they give the staff copies of the reports that they made at the scene of the incident. This allows hospital personnel to fully understand how the subject's behavior at the scene prompted the volunteers to recommend treatment. For example, the staff may observe a calm individual who tells them, "I was just sitting at home when the police busted in and brought me to the hospital." The volunteers' report reveals that, in reality, the individual was wrecking the house and threatening to commit suicide. This reporting method leads to a more thorough evaluation of the subject, rather than a quick, superficial examination and release.

In another aspect of the program, mental health professionals from local hospitals often ride along with crisis service volunteers when they respond to psychiatric emergencies. In this way, they can see the program at work while developing a clearer picture of the mental health of residents in their communities. Working together, the mental health personnel and the crisis service volunteers can treat individuals with mental illness humanely and with dignity and ensure that these subjects receive the most appropriate services available.

CONCLUSION

The successful resolution of psychiatric emergencies illustrates the effectiveness of timely, appropriate intervention. However, for too long, law enforcement officers; not trained mental health workers, have had to shoulder the burden of responding to situations involving violent individuals with mental illness. The New Orleans, Louisiana, Police Department developed a unique and cost-effective method of handling these types of incidents by creating a crisis service staffed by trained volunteers who intervene in psychiatric emergencies, conduct mental health examinations at the scene, and transport subjects to hospitals when appropriate.

This service can benefit the police, the community, and individuals with mental illness. Police officers can concentrate on the law enforcement duties for which they are trained; communities can save money by using trained volunteers rather than officers to intervene; and individuals with mental illness can receive more appropriate services. Additionally, mental health professionals can see firsthand what police officers face when a psychiatric emergency occurs in their community. In short, the New Orleans Police Department's Mobile Crisis Service shows how cooperation between law enforcement and mental health officials can bring about a positive change in law enforcement's response to individuals with mental illness.

Mr. Jeff Wellborn is the program administrator for the New Orleans, Louisiana, Police Department's Mobile Crisis Service.