Understanding Subjects with Paranoid Schizophrenia.

Throughout their careers, law enforcement officers may encounter individuals who have paranoid schizophrenia. Some of these individuals may not have a home and may actually live on the street. They may dress in layers of shabby clothing and have poor personal hygiene; but contrary to this outward appearance, many of these people are harmless. Fortunately, doctors can prescribe medication to treat most phases of schizophrenia. However, individuals with schizophrenia may refuse or ignore their prescribed medications because they dislike the side effects or cannot afford the medication. Some individuals may deny their illness altogether. At this point, they become at risk for committing violent acts, which may bring them into contact with law enforcement.

Law enforcement first responders and negotiators must understand individuals diagnosed with paranoid schizophrenia by learning the characteristics they may exhibit. This understanding will help officers respond to these individuals and peacefully resolve conflicts with them.

SYMPTOMS

A variety of symptoms characterize a person living with paranoid schizophrenia. Generally, these symptoms are present in individuals who remain untreated or unresponsive to their medication. All of the symptoms of paranoid schizophrenia cause major social or occupational dysfunction, and experts cannot explain the symptoms by some other disorder, such as drug abuse or a medical condition. Individuals with schizophrenia will have two or more of the following characteristic symptoms, each of which exists for a significant portion of time during a 1-month period (or less if successfully treated): [1]

* delusions;

* hallucinations;

* disorganized speech;

* grossly disorganized or catatonic behavior; and

* negative symptoms (no emotion).

A delusion is an erroneous or false belief that usually involves a misinterpretation of perceptions or experiences. The delusion may be somatic ("My body is rotting on the inside"), persecutory ("They are trying to poison me"), religious ("I am on a mission for God"), referential ("That actor on TV was sending me a special message"), or grandiose ("I am God"). Most frequently, however, the themes are persecutory, hence the descriptive label paranoid." Delusions may range from the bizarre ("I was kidnapped and am now being stalked by aliens") to the merely paranoid ("People at work are conspiring against me").

Hallucinations can be associated with any one of the five senses, but subjects most frequently experience auditory hallucinations. That is, they hear voices, distinct from their own thoughts, that are usually critical, demeaning, or threatening.

Several subtypes of schizophrenia exist. The paranoid type is characterized primarily by delusions or auditory hallucinations in the context of otherwise-normal cognitive and emotional functioning. Compared to other forms of schizophrenia, paranoid schizophrenic thoughts are coherent, and delusions generally revolve around an organized theme. Anxiety, anger, aloofness, and argumentativeness are common symptoms associated with this illness. Furthermore, individuals often will have a superior or patronizing manner. The persecutory themes may predispose individuals to suicidal behavior, and the combination of persecutory and grandiose delusions with anger may predispose individuals to violence. [2] The fact that many who have paranoid schizophrenia have coherent thinking that accompanies consistent delusions makes them potentially lethal. Although they misperceive events, their behavior is generally organized, making them capable of significant, premeditated, goal-directed behavior. [3]

PREVALENCE, CAUSES, AND TREATMENT

At least 1 to 2 people out of 100 will be diagnosed with schizophrenia at some point in their lives. [4] An estimated 2.5 million Americans live with schizophrenia, and about one-third of them have paranoid schizophrenia. [5] Prevalence rates are similar throughout the world, and typically, the onset occurs in the late teens to mid-30s, with men more likely to have an earlier onset. Delusions and hallucinations will have content consistent with cultural beliefs and practices of people from other cultures. For example, a Russian immigrant with a mental illness may have concerns about the KGB.

Evidence exists for a strong genetic or biological component to the disorder because first-degree biological relatives of individuals with schizophronia have a 10 times greater risk of developing the disorder than the general population. At the same time, twin and adoption research studies have shown that environmental factors also can play a role in the development of the disorder. [6] In any event, evidence shows that the disorder is a biologically based illness, and many of the available treatments are antipsychotic medications. These medications can cause such side effects as involuntary movements of the tongue, jaw, trunk, and extremities, which require additional prescriptions to control. In addition to taking this medication, people with these disorders may need outpatient therapy or inpatient hospitalization, placement in group homes or board-and-care facilities, or require institutionalization.

In fact, prior to the 1960s, doctors often institutionalized patients with schizophrenia. However, this pattern began to reverse in the 1970s due to the advent of antipsychotic medication, changing attitudes of individuals toward people with mental illness, revelations about poor conditions at hospitals, and concerns about costs. This pattern accelerated in the 1980s and continues today. [7] While many people with schizophrenia can live more normal lives in the l990s, a lack of funding for community-based care has led a number of these individuals to deteriorate and lapse into behavior that law enforcement now must address. Experts estimate that more than one-half of all people with schizophrenia receive inadequate therapy, while fewer than 30 percent get appropriate medication. Some mental health experts believe that the burden of responsibility and risk is shifting to law enforcement. [8]

VIOLENCE RICK AMONG PEOPLE WITH SCHIZOPHRENIA

At one time, despite public perception of a connection between mental disorders and violence, social science researchers firmly believed that none existed. [9] However, recent research demonstrates that the prevalence of self-reported violence among those with schizophrenia remains 5 times higher than those with no disorder and that schizophrenia remains 3 times higher in jail and prison samples than in general population samples. [10] In particular, those who actively experience psychotic symptoms, such as delusions and hallucinations, are involved with violent behavior at rates several times higher than members of the general population with no disorders. [11]

If present, several factors or activities may elevate the risk of violence. The most common of these is alcohol abuse and illicit drug use. Weapons possession represents another common element because when individuals with paranoid schizophrenia believe they are not safe, they are more likely to acquire weapons to increase their sense of power and safety. These factors, combined with these individuals' near-absolute distrust of everyone and their delusions and hallucinations, can turn them into potentially violent, unpredictable, and dangerous adversaries for law enforcement. When individuals possess all of these elements, law enforcement faces the problem of trying to control a person who feels directed to complete a "task" and, at the same time, due to paranoia, has become totally distrustful of any police involvement.

Those subjects who believe that other people intend to harm them may make a "preemptive strike" to keep themselves safe, while others may have "command hallucinations" (i.e., they hear voices) that tell them to harm others. Further, certain delusional beliefs may compel individuals to commit illegal acts that can escalate into confrontations with law enforcement. These subjects' actions challenge law enforcement's resourcefulness to prevent acts of possible violence or long, drawn-out confrontations.

Case Examples

Recently, several violent incidents have occurred involving law enforcement and individuals diagnosed with paranoid schizophrenia. In Washington, DC, on July 24, 1998, a man killed two U.S. Capitol police officers. The suspect reportedly believed that he had been cloned at birth, that he had invented a machine to reverse time, that the CIA had been spying on him through satellite dishes, and that President Clinton had planned the Kennedy assassination out of jealousy over Marilyn Monroe. [12] The subject had numerous prior contacts with local law enforcement and the U.S. Secret Service prior to the killings and had been committed previously for mental health reasons.

The now-infamous Unabomber allegedly committed 16 bombings between May 25, 1978, and April 24, 1995. His 17-year serial bombing spree left 3 people dead and 28 others injured. He believed that the power of society to control the individual was expanding rapidly and that this progress, if not stopped, inevitably would lead to the extinction of individual liberty. [13] He also asserted that he was entitled to embark upon a bombing campaign in service of his antitechnology beliefs.

In the fall of 1997, a middle-aged woman in Roby, Illinois, barricaded herself in her residence for over 5 weeks while law enforcement officers attempted to serve a mental-health-commitment order. During this period of time, she fired at officers and shot a police dog. She believed that her food was being poisoned, that FBI personnel were trying to rape her, and that her family members were imposters trying to steal her money and harm her. After 39 days, the police took her into custody while she was trying to disable a covert surveillance camera. After 47 days in mental health custody, doctors released her, and she returned to her rural residence. [14]

Delusions, hallucinations, and general paranoia contributed in influencing the violent behavior of these individuals. When confronted with a person who exhibits unusual or potentially dangerous behavior, law enforcement officers should not focus on criminal responsibility, but rather on how they should respond to the person to deescalate the situation and maintain safety.

CRISIS MANAGEMENT STRATEGIES

Incident Prevention/ Early Intervention 

Ideally, management and intervention of potentially violent citizens with paranoid schizophrenia, as well as other disorders, begin with early recognition of an evolving problem. Prior to committing acts of violence, many subjects write letters, make telephone calls, and use other methods to communicate with those in the community and law enforcement. They often express concerns about hearing voices or being followed or have various other delusional beliefs. In addition, other individuals--for example, family members and private security employees-- may bring the person to the attention of law enforcement because of these behaviors. [15] At this point, officers can assess individuals for risk and divert them to systems that can keep them from moving from thinking to acting. Unfortunately, all too often, when individuals call or send obscure complaint mail, law enforcement may merely view them as a nuisance, thus missing opportunities for assessment and early intervention prior to the development of a major p roblem.

Police officers can use numerous techniques and resources to assess threatening and desperate communications and behaviors. For example, law enforcement and mental health professionals can respond as teams to evaluate and intervene with citizens who have deteriorating conditions. Also, officers may conduct proactive interviewing of "problem" citizens in order to monitor signs of deterioration or escalation. Law enforcement also should increase its attention to mental health needs and intervention during sentencing phases of criminal trials involving individuals with schizophrenia, particularly if the individual will be released someday. Although police administrators should determine the best approach for their departments and communities, proactive evaluation of these situations by law enforcement should include considering--

1) whether such individuals are organized and coherent versus disorganized and unable to engage in goal-directed behaviors;

2) whether such individuals stay fixed on one or several major themes or explanations for their concerns that involve blame for significant problems in their lives versus not having "figured it out" yet;

3) whether such individuals focus on a specific person or several persons versus not having determined who or what is behind it all;

4) whether such individuals have an action imperative where they believe that they have exhausted the legitimate avenues of addressing their issues and now believe that they have to take matters into their own hands; and

5) whether a time imperative exists, and such individuals communicate a sense of urgency or desperation about the need for such actions. [16]

Individuals who demonstrate these factors elevate law enforcement's degree of concern and need to intervene. These factors remain particularly important if the subject has a history of violence, delusions and hallucinations, active substance abuse, weapons access, situational stressors, and a lack of positive influence or social support. Many of these individuals communicate with law enforcement for years at a relatively innocuous level, when suddenly--usually due to medication issues, situational stressors, or other factors--the level begins to escalate.

Still, a distinct difference exists between posing a threat and making a threat. Researchers have noted that some who make threats do not pose threats, and some who pose threats do not make threats. [17] Nonetheless, law enforcement agencies should have a mechanism in place for monitoring these individuals prior to an incident. For example, the Los Angeles Police Department has a Threat Management Unit and Mental Evaluation Unit that perform these functions; the FBI has the Critical Incident Response Group; and the U.S. Secret Service uses its Intelligence Division for such monitoring. Smaller agencies also can apply and adapt the models used by these larger organizations to serve this monitoring and early-intervention function.

Intelligence Gathering

Intelligence gathering begins with the initial 911 call or request/inquiry from the reporting party. The citizen who files a report because of concerns about a subject often will include information about possible paranoid schizophrenia. The person taking the initial report should gather as much information as possible, particularly about mental health problems, and immediately report it to the responding officers. Additionally, dispatchers should provide officers with the information they need to avoid fulfilling any delusions or hallucinations. Also, police should seek all available information from the individual's mental health professional, who may furnish treatment history, medication compliance, and past propensity for violence.

Frequently, escalating events (e.g., telephone calls) may have preceded the current law enforcement contact. Officers should try to understand this history as fully as possible and access as much relevant data as possible, particularly about past communications. Police should use a mental health consultant, if available, to assist in the data-gathering and interpretation process. In hostage incidents, search warrants to the subject's residence or other frequented locations may yield materials (e.g., diaries or letters) that can help others understand the current situation.

Verbal and Nonverbal Strategies

First responders or negotiators can use a variety of verbal and nonverbal strategies when engaging subjects with paranoid schizophrenia. First, and most important, officers should show respect and interest in subjects and their concerns. The initial verbal contact that officers make during a crisis or hostage situation may set the tone for the remainder of the contact, prove instrumental in determining the outcome of the situation, and dictate the tenor of all future encounters.

Officers should contemplate how the subject may perceive their comments. Nonconfrontational statements such as "Hello, how are you? I am Officer Smith" are neither alarming nor threatening. These types of comments, spoken in a calm and even tone, project a sense of respect and dignity. In crisis situations, officers' initial comments will provide the cornerstone for the success of the entire operation and establish the foundation for all future contacts.

Next, officers should take an unemotional, logical, and factual approach, seeking to understand the important issues that subjects are trying to communicate. No matter how bizarre the delusions or hallucinations may seem, officers must maintain their professional demeanor and not ridicule or criticize subjects in any manner. Subjects believe their issues are serious, and given their paranoia, they may not perceive laughter very kindly but rather as demeaning. Officers can give a response that shows interest and concern by law enforcement, at the same time projecting non-aggressive, nonconfrontational communication. For example, officers can say, "I understand what you are saying, but I do not hear those voices. Can you tell me more about them?" Individuals with paranoid schizophrenia trust very few people, if any. They do not understand why others cannot see, hear, or feel what they do.

Friends and family may have told the person that the delusions and hallucinations they sense do not exist and may have even ridiculed them. Therefore, officers can establish a rapport with subjects by showing a willingness to understand and help. Officers should not tell individuals that the "mission" they are on or the "messages" they receive do not exist because the individual truly hears and believes these delusions and hallucinations. By paying attention to these concerns, first responders and negotiators work to establish credibility with the subject, showing that they are different from others whom the subject previously perceived as threatening or humiliating.

In addition, negotiators have found that using third-party intermediaries to negotiate with suspects may have a positive impact upon many incidents. [18] However, due to past negative interactions with the subject and the possibility that the family member or previous mental health provider may contribute to any existing delusions, it remains critical that officers assess the subject's perceptions of any third parties before allowing them to become involved in the process.

Experts disagree on the usefulness of talking with subjects about the content of their delusions, but officers must remember never to argue with them. Some experts believe that law enforcement officers should understand subjects' delusions to avoid actions that may fulfill these delusional beliefs; some believe that officers should immediately move to reality-based issues. In either case, sometimes subjects will need to talk about their delusions, and first responders and negotiators should listen to their explanations of the world and respond sincerely. In doing so, officers should not say that they see or believe the things that subjects do, but they can say that they believe the feelings and sensations. For example, an honest, yet productive, response from law enforcement might be "I believe you are scared and not sure whom to trust. I can tell you that I haven't seen them, but it is clear that you believe you have. That's important to me." A response toward more reality-based issues might be, "If you kil l yourself for the cause, I'm concerned about who will look after your children."

Experienced negotiators have learned that they may become targets of verbal abuse when dealing with subjects with paranoid schizophrenia. In fact, these subjects often express a fair amount of rejection, anger, and fear to first responders or negotiators. First-responding officers should allow this ventilation, paraphrase the subject's concerns and feelings, and reassure the subject that they (the officers) are different from others. Officers may precede such reassurance by suggestibility statements that confirm the officer's s sincerity, such as "You have had every reason to not believe what I am going to tell you now...." or "It makes sense that you would feel that way; maybe later you might decide that I am worthy of some of your trust."

Direct attempts by officers to force trust upon individuals with paranoid schizophrenia will only reconfirm the subjects' worst suspicions about officers--that they cannot be trusted or intend to harm or humiliate them. Experienced negotiators have learned that allowing subjects to vent frustrations at law enforcement reduces their anger, fear, and energy. A positive aspect of this type of ventilation comes from the subject's concentration on law enforcement, which redirects anger from any hostages, provides a verbal alternative to more violence, and may distract the subject from devoting additional time and energy to fortify any stronghold or dwelling. All of the subjects' comments can provide valuable information for negotiators to keep the subjects talking rather than hurting others. Additionally, such delay tactics give the crisis management team crucial time to develop strategy, obtain evidence, and plan and rehearse tactical options.

However, if ventilation appears to escalate the subjects' anger or fear, officers can distract subjects to focus their attention on other issues. In certain situations, it may help to change the topic to something unrelated such as the subjects' hunger or personal needs. As long as subjects do not perceive it as an uncaring shift, such a tactic may deescalate a particularly inflammatory course of dialogue. Interestingly, and potentially important in a negotiation situation, many people with paranoid schizophrenia have a nicotine dependence (e.g., cigarette smoking), and nicotine dependence may reduce medication side effects.

The physical boundaries of the encounter also play a crucial role in such situations. Subjects may perceive such things as body space, eye contact, and the mannerisms of the responding officer or negotiator as potentially threatening. Officers should remember that subjects may require more physical distance in interactions in order to feel safe. Further, too much intense eye contact in face-to-face scenarios sometimes evokes some fear of aggression or mind control.

Similarly, movements by individual officers or the tactical team will be filtered by subjects through the emotion of fear and anticipated aggression, and subjects may feel a need to act first in order to keep themselves safe. Subjects may perceive everything an officer does as a threat. Therefore, without compromising the operation, officers should tell subjects what they plan to do before taking any action.

If successful, these interactions lay the foundation for a relationship in which the subject experiences a sense of security and safety. It may take a long time for officers to build rapport with individuals who do not trust them and who have concern for their own well-being; once officers establish rapport, however, they can shift some of the focus to problem solving. As officers explore the range of alternatives to resolve the situation, they must never doubt subjects' intelligence, even when the subjects present some rather bizarre scenarios and concerns. When discussing options that might help to resolve subjects' concerns, officers always should avoid insulting their intelligence. [19]

After resolving the incident, officers must practice the basic negotiation concepts--fulfill promises as much as possible and continue to build rapport after arrest or surrender. Officers must recognize that they may deal again with subjects who get released. Officers should continue to show respect, interest, and thoughtfulness in their interactions with subjects. In addition, they should share information with hospitals, doctors, and family members to expedite social support and assistance. Oftentimes after an incident, another patrol unit takes the individual for arrest processing, and critical information does not get passed to those who may play an integral role in preventing a future incident. Effective case management and prevention begins anew, and law enforcement officers must recognize the importance of their roles at this stage.

Physical Tactics/Alternative Strategy Considerations

The use of physical tactics to resolve incidents raises important concerns. First, law enforcement has encountered an increasing number of barricade situations involving subjects with paranoid schizophrenia, as well as other criminals, who seek refuge in their residences and refuse to leave. Their homes may provide a place of solace, holding fond memories. As a result, when officers plan to arrest subjects at their residences, the likelihood of violence may increase. Close, threatening containment also may prove counterproductive.

In some cases, subjects may increase their personal body space to include their residences. For example, when officers tried to serve a court order to the woman at her home in Roby, Illinois, she met them with a shotgun and refused to surrender. As the situation continued, her body space increased to the approximate dimensions of her residence. When tactical officers attempted to peer into windows and to open doors, she fired on them, believing they were invading her personal space.

Many individuals with paranoid schizophrenia also form strong attachments to particular possessions and to their pets. If tactical officers kill pets or destroy or damage certain possessions, they may seriously undermine any potential for negotiators to develop rapport with the subject. Law enforcement should take such actions only when absolutely necessary. Excessive noise, tactical movement, and other law enforcement actions will be magnified to subjects with paranoid schizophrenia, and crisis negotiation teams should limit their use of such tactics to avoid exacerbating subjects' fears and anxieties.

The subject's shame at being apprehended in front of an audience likewise can inflame a situation. Officers should consider alternative plans devised to lure unsuspecting suspects from their residences prior to an arrest attempt. For example, if officers disable a heater or air conditioner, subjects may let their guard down while trying to fix the problem. Such a ruse may reduce the likelihood of officers' being fired upon.

At times, police may even consider merely walking away from a situation, after determining that the reason for law enforcement involvement is not worth the deployment of significant resources. [20] Often, an agency may deploy some officers nearby to take subjects into custody when they leave their safe haven.

INCIDENT ASSESSMENT

How law enforcement addresses subjects with paranoid schizophrenia, as first responders or negotiators, may dictate a peaceful or violent outcome. While assessment and understanding of one factor--suspect type (depressed, personality disordered, or psychotic)--remains important, four other factors play a significant role in the outcome of these events:

* the context of the event (spontaneous, deliberate, or anticipated criminal event); [21]

* expressive versus instrumental demands or agenda (subject in crisis and needs to vent concerns versus more concrete demands such as social or political change);

* hostage presence and type; and

* law enforcement's crisis management actions. [22]

Ideally, careful consideration of the first four factors should appropriately dictate law enforcement's crisis management actions in order to ensure optimal success.

CONCLUSION

Experience has shown that officers who receive negotiation training handle individuals with emotional problems better than they did before training, even when the initial contact is a standard call for service. Officers have learned specific guidelines for communicating with and managing these people, as well as crisis intervention skills that prove helpful in resolving conflict when dealing with those with paranoid schizophrenia.

Trained negotiators realize that trying to resolve any problem or crisis too quickly will have negative results. Through the use of crisis intervention techniques, negotiators and first responders may spend many hours talking to individuals with paranoid schizophrenia and successfully change their behavior. The ability to establish rapport, show genuine interest and concern for the subject, and maintain a credible posture has enabled many negotiators and first responders to orchestrate peaceful resolutions to potentially violent situations. Anytime a peaceful resolution results, a double victory occurs for law enforcement--the situation ends without violence, and tactical team members do not need to take any unnecessary action or place themselves in harm's way against an unpredictable, violent person.

Dr. Mohandie serves as a police psychologist with the Los Angeles, California, Police Department's Behavioral Science Services Unit.

Special Agent Duffy is assigned to the Crisis Negotiation Unit at the FBI Academy.

Endnotes

(1.) American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed.): DSM-IV (Washington, DC: American Psychiatric Press, 1994), 286.

(2.) Ibid., 287.

(3.) Organized behavior refers to behavior that is purposeful and based upon logical and sound thought processes, compared to disorganized behavior where an individual engages in behavior that is more chaotic, unpredictable, and impulsive, as a function of a clouded and confused thought process.

(4.) Supra note 1.

(5.) M. Grunwald and S.G. Boodman, "Weston Case Fell Through Cracks; Violence by Mental Patients Hard to Predict, Experts Say," The Washington Post, July 28, 1998, Al.

(6.) Supra note 1, 283.

(7.) Supra note 5.

(8.) "Capitol Case Puts Family Nightmares in Spotlight," in Associated Press, August 5, 1998.

(9.) J. Monahan, "Mental Disorder and Violent Behavior: Perceptions and Evidence," American Psychologist 47 (1992): 511-521.

(10.) Ibid.

(11.) Supra note 1.

(12.) Supra note 5.

(13.) S. Johnson, "Forensic Evaluation of Theodore John Kaczynski" (unpublished forensic report, January 16, 1998).

(14.) M. Campion and D. Brown, "The Roby, Illinois, Incident: The Longest Standoff in American History," paper presented at the International Association of Chiefs of Police Annual Conference, Salt Lake City, Utah, October 17, 1998.

(15.) R.A. Fein and B. Vossekuil, Protective Intelligence and Threat Assessment Investigations: A Guide for State and Local Law Enforcement Officials (Washington, DC: U.S. Department of Justice, 1998).

(16.) C. Hatcher, "A Method for Assessing Threating Communications" (unpublished manuscript, 1998).

(17.) Supra note 14.

(18.) "The Police Seminar on Crisis Negotiations," seminar presented by the FBI, Burbank, CA, October 5-8, 1998.

(19.) M.J. McMains and W.C. Mullins, Crisis Negotiations: Managing Critical Incidents and Situations in Law Enforcement and Corrections (Cincinnati, OH: Anderson, 1996).

(20.) M.S. Miron and A.P. Goldstein, Hostage (New York: Pergamon, 1979).

(21.) F. Lanceley, "Criminal Contexts of Hostage Incidents" (unpublished manuscript, 1997).

(22.) K. Mohandie and M. Albanese, "Advanced Crisis Negotiations" (unpublished manuscript, 1997).

Negotiation/First Responder Guidelines

1. From the beginning to the end of the contact, strive to show respect and dignity through verbal comments and physical actions.

2. Make a noticeable attempt to understand the context of the subject's comments.

3. Avoid arguing about the subject's delusions while attempting to develop reality-based issues.

4. Use active listening skills such as paraphrasing, emotion labeling, and "I" messages.

5. Use suggestibility statements and empathy to attempt a behavioral change.

6. Allow the subject to vent frustrations.

7. Do not crowd or violate the subject's personal body space, which may encompass an area as large as a residence or dwelling.

8. If rapport appears to be developing, use terms "us" and "we" instead of "you" and "me."

9. Fulfill promises made to the subject.