Thursday, August 23, 2012

Call the Police

What should you do if you believe someone is dangerous?  It's a sticky issue in psychiatry.  Here in Maryland, the requirements to have someone brought to an emergency room for evaluation by two physicians, include an imminent risk of dangerousness and the presence of a mental disorder.   If an emergency petition is signed by a judge, the police pick up the person in question and bring him to an emergency room for an evaluation.  In the ER, doctors can decide to certify the patient to an inpatient unit for further evaluation, or they can release the patient.  If admitted, a hearing must be held within 10 days.

Who else can file a EP?  Well, the police can.  If someone acutely agitated and violent and there is no time for a family member or interested party to obtain an EP, the police can be called and they have the option to fill out an EP and take the person to the hospital without a judge okaying the EP.  Depending on the circumstances, they also they have the option to arrest the individual and bring them to jail.   Finally,  a doctor can file an EP, but s/he must have seen the patient (--you can't get tell your rheumatologist-neighbor about your ill relative and get him to file an EP). 

So the police come -- either because they've been called in an emergency, or because a judge has authorized them to take someone to the hospital.  Most of the time, this goes smoothly.  But it doesn't always, especially since the person involved is presumably mentally ill and dangerous (the criteria for getting the evaluation).  Sometimes things get very upsetting, and sometimes they go very badly and someone gets hurt. 

In today's Baltimore Sun, there is an article by Justin Fenton that questions whether our police have the proper training to handle these crisis situations:

Baltimore Police have shot 10 people this year — eight of them fatally — leading some to question whether police are properly equipped to handle calls involving the mentally ill.

Only one of those shot was carrying a firearm, and several shooting incidents arose from calls to police about a disturbance involving someone with a mental illness. Relatives of some of those killed criticized police tactics, saying they shouldn't have lost loved ones after calling police to defuse situations that had ended peacefully in the past.

These are difficult situations, sometimes with no answer that will lead to a good outcome.   Fenton continues:

The director of the city's mental health organization praised the Police Department's training effort and said services for the mentally ill are lacking.

"If we don't do a good job getting people into treatment and something bad happens, we look to the Police Department and ask why did this person get shot," said Jane Plapinger, the president and chief executive officer of Baltimore Mental Health Systems. "Maryland is one of the best, but we unfortunately have an underfunded public mental health system everywhere in this country."

The Behavioral Emergency Services Team, or B.E.S.T. training, was implemented in 2009 and teaches officers to de-escalate mental crises, minimize arrests, decrease officer injury and direct patients to the city's mental health crisis programs for help. It has become mandatory for recruits.

"The police have been such a steadfast partner — I don't know how many [other] police departments are devoting four full days to this kind of training," Plapinger said.

The patients aren't the only ones in danger.  Police officers, or others, can be injured in these struggles. While it's not like there is an obvious answer besides calling the police, if the situation does not involve immediate danger, I often suggest that family member work to de-escalate upsetting situations and  convince a patient to go for help voluntarily, or with coercion, because even if it's coerced, these situations are often less upsetting for the patient and less dangerous for everyone if they can be done without the police.  Of course, this involves 20-20 hindsight, and the use of a crystal ball, because if there is a bad outcome and someone is injured or killed, then calling the police would have been a better solution.

I do wish I had that crystal ball. 


RobotRobot said...

What happens if a person is not dangerous to anyone else, but not able to look after themselves in very basic ways? Mental health professionals in CA are suggesting I call the police on a friend who is not suicidal because they can put her on a 72-hour hold as "gravely disabled". But doesn't it seem weird that me John Q Public can have someone hauled away? I'm glad to see there's an EP in Maryland.

Dinah said...

I am leaving these criteria to Clink, this is really her area of expertise. She wrote a whole section on this in our Shrink Rap book.

Anonymous said...

as someone who was married to a cop, a lot of these problems they dealt with were actually people that had a dual diagnosis - mental illness with an alcohol and drug abuse problem. The problem here is that there are next to no beds in the jail or the psychiatric unit, so these individuals end up getting streeted and only a very few get the treatment they desperately need.

And although law enforcement personnel do get training, it is not enough. mental illness is such a wide spectrum and the only people that know it intimately are the sufferers, family members and those trained in the mental health field.

Dinah said...

Anon-- sometimes family members and mental health workers end up dead, too.

I think the issue is to strive for doing all that can be done. There are ways of de-escalating upset people, but they don't work with everyone in every circumstance.

Given a number of police-involved shootings, it does seem reasonable to at least ask the question of whether something more could have been done. The answer might be no?

George Dawson, MD, DFAPA said...

Of course a lot more can be done and it can be done successfully. Here is a link to a highly successful organization that has worked successfully to reduce violence at every step of the way including post incarceration:

Read the "About Us" section to see how they got started.

Anonymous said...

Something more can always be done, but pretty much it boils done to $$$. Money for more training, money for more law enforcement personnel, money for more jail beds, money for more psychiatric beds, money for more mental health experts... Where does that money come from?

Instead, we have had all of those things dwindling away bit by bit in my community. I suspect that this is the case in most communities in the U.S. as well.

I know our police force relies more heavily on tasers in our community now, so officers can move in on an unruly suspect without getting hurt in certain situations.

O.K. I'll stop... I'm jaded. :)

Roy said...

A few clarifications...

"gravely disabled": Maryland does not have such a statute, though clinically we have recognized inability to care for self due to a mental disorder as a reason for involuntary hospitalization if there is some evidence that their life or health is in danger. Note that dementia alone is not a qualifying condition nor is substance abuse alone.

"imminent" danger: Clink, correct me if I'm wrong, but Maryland does not use the concept of imminence, at least not in the certification standards. Here is a link to the various commitment forms for your perusal. Below are the "six questions" that two physicians or one physician and one psychologist must satisfy for involuntary admission:

1. The individual has a mental disorder;
2. The individual needs inpatient care or treatment;
3. The individual presents a danger to the life or safety of the individual or of others;
4. The individual is unable or unwilling to be admitted voluntarily;
5. There is no available, less restrictive form of intervention that is consistent with the welfare and
safety or the individual; and
6. If the individual is 65 years old or older and is being referred for admission to a State facility, geriatric evaluation team has determined evaluation team has determined that there is no available, less
restrictive form of care or treatment that is adequate for the needs of the individual.

Hearings: Dinah said that hearings must be within 10 days. This is correct although the attending physician can request a 7-day extension. This is unusual (maybe 1 in 10), and the patient/attorney must agree to the extension.

Who can file an EP? Dinah mentioned physicians and police. Also included are social workers, nurse practitioners, professional counselors, and probably a few others. Also, anyone can go to a judge and request her to execute an EP based on information the petitioner provides to the judge. I've seen this method be abused sometimes.

Dinah mentioned families should try to settle the person down rather than call the police. I agree. But, I've seen many situations where I am certain that what happens is a family member intentionally pushes someone's buttons and riles them up so that they become violent, and THEN they call the police. Note that the police have discretion about this, so if one is completely calm and reasonable, it is unlikely that the person will be taken in. But if they are yelling or furniture is overturned, etc, then someone is probably being taken in.

Police officers receive extensive training in most jurisdictions on interacting with people whose judgment may be impaired due to mental illness. Some have trained mental health professionals who meet them at the scene.

I must say, I do hear about these situations where it seems the police use excessive force. I recall a situation many years ago in Baltimore where a confused old lady was brandishing a pair of scissors. At gunpoint, she refused to put them down and apparently advanced towards the officer, who shot her dead.

Really? Aren't there less deadly methods for stopping a demented scissors-wielding senior citizen. Bean bag gun? A net? Newspaper coupons?

I'm not in that business, and I understand it is high-risk and one must make split-second decisions, so I try not to judge, but you do wonder.

Final comment: rather than call the police, there are often city or county helplines that can be called. They can help de-escalate a situation, sometimes even respond with services.

Roy said...

Oops, I left out the link to the commitment forms.

Anonymous said...

I doubt you will post my comment but please watch this video.

I had was taken in to hospital by police. I had no weapon of any kind. I was agitated, off my medications and my family called 911. I was not physically threatening to two cops, each of whom probably tipped the scales at about 100 pounds more than I do and each of whom had a gun. The police did not shoot me but I have never been manhandled so brutally and spoken to so cruelly as by those two with the exception of when someone in my life beat me or abused me. Your graphic is difficult to look at. It feels as though it was made to mock people who have had this experience and worse. It makes me very sad.

Dinah said...

Dear Last Anon--
The comment moderation is on to block rudeness and spam, not to stop people from saying "this upsetting thing happened to me" or "I disagree with you." It's all about delivery, not the message, and your delivery was fine (almost everything gets past moderation).

It's a horribly upsetting video.

Pete Earley's book Crazy really does a great job of talking about flaws in the system and how some police forces have better training than others.

I'm sorry if the graphic upset anyone. They are generally chosen quickly, sometimes I find stuff that is very appropriate and other times, I use what I find quickly. They are really just meant as a visual to draw your attention in and make the blog as a whole more appealing, rather then just having text. My thinking on these things is that I can't please all the people all of the time, and that one objection is one person's opinion. If two people object, I take it down. If anyone else wants the graphic down, just say so. It was not intended to mock or to make light of a serious situation. For this particular story, I did not want to use a graphic of a police officer with a live police officer because I didn't want to imply that that particular officer had shot anyone, so I went with a cartoon.
I was going to use a police car, but they also had town names on them and I didn't want to imply that any particular police force was particularly violent towards mentally ill people.

I'm sorry to hear you had such a distressing experience. I am all in favor of a kinder, gentler system.

Anonymous said...

Thank you for posting. I was thinking that you would not post because of the distributing video. I am not asking you to remove the graphic. It is so out of touch with my experience but it is not offensive in and of itself. I am saddened by it but I am also deeply saddened by the video link I shared with you. Perhaps you achieve balance by allowing people to view both.
We do need a kinder gentler system and yes, it will cost money. On the other hand, our present system costs lives.
If those two cops passed me on the street today, they would see nothing more than someone carrying groceries home to cook dinner for a family.

Anonymous said...

I could also live without predictive text while I type. I meant disturbing, not distributing.

Anonymous said...

I was petitioned twice, both times by a former housemate, both times for being seriously depressed. The experiences each time were so different it leads me to believe that any training that exists is not very effective. The first time I was home alone reading on the computer. Not agitated, not violent, not intoxicated. Just quietly reading. The police knocked on the door, held up a piece of paper and said a judge had signed it, I opened the door, and the next thing I knew I was face down on the floor, arm twisted behind me, knee in my back, and then handcuffed. I was in my pajamas. They wouldn't let me change, call anyone, get any shoes. They kicked my dog (who is friendly) and wouldn't let me check on her. Finally one of them grabbed a pair of shoes (dressy sandals) from the closet and they walked me half a block up the street to their car. I don't know why they didn't park in the empty space right in front of my house. Every interaction they had with me was at top volume and they made a point of jerking me around by the arm. Handcuffs are quite painful, as it turns out.

The second time they came to the door I was teleworking. These police officers were polite and respectful. They let me change my clothes. They let me arrange care for the dogs. They apologized for needing to handcuff me (the rules). They did not jerk me around painfully. They wished me well when they left me at the hospital.

Both times in the psych ER I was seen by a physician and a psychologist. Both times these two people agreed that I did not need inpatient treatment. Both times they were overruled by a third person (MD). Both times I agreed to be admitted as a voluntary patient and both times I was admitted as an involuntary patient (which makes life much harder).

I have no idea why the two situations were so different.