The myths and risks to individuals with mental illness

WESTBOROUGH, MA April 8, 2018 The myths attributed to persons afflicted with mental illness need to be directly addressed and corrective programs must evolve provide enhanced understanding and awareness of mental health.  Police officers encounter citizens with mental illness daily and often are called upon to calm a volatile situation often with very little formal training. This fact is changing as more police officers are trained in Psychological First Aid and Crisis Intervention Training – 2 programs that afford front line officers with the behavioral observation skill and communication necessary to reduce risk to police and the public from highly charged persons exhibiting signs of mental health crisis.
Psychological experts believe mentally ill persons lack the higher order planning to execute the complex steps necessary for anything more than petty crime – more often associated with co-morbid substance abuse.  This is where the problem lies. “The myth is you have to be “crazy” to do something like this (active shooter). So retrospectively, you look at people and you say, wow, this obviously – that guy should have been branded – but alcohol accounts for a great deal more violence than mental illness does.” according to Joel Dvoskin in an APA interview dispelling myths about the mentally ill.
Remember it is a fact that those with mental illness are rarely violent and those who commit violence are rarely mentally ill.
Until recently,  here in Massachusetts many smaller police agencies are forced to pay overtime for police officers to sit in hospitals or outside of jail cells watching a mentally ill person who has been arrested. This policy grew from the fear of litigation if someone dies in police custody who is known to be a mentally ill person.  Specifically, if a police officer arrests a person with a known history of suicidal ideation it has been policy among many agencies to provide an officer to monitor the prisoner to assure for a safe transfer to court. If this occurs on a week end night that often means that someone must have eyes on the person in custody until the next available court date.
But is this truth or is this part of the myth associated with those taken into custody for crimes committed while suffering from a substantive mental illness? Or is the problem really associated with substance abuse?
“Pre-arrest diversion also has been shown to be successful when law enforcement and mental health professionals respond together to behavioral health emergencies. Individuals are more often referred to the services and treatment that they need, rather than enter the criminal justice system as an offender. This co-responder model has delivered great results in Massachusetts to date. Programs run by Advocates, a human services agency, in partnership with several police departments in Middlesex County and funded in part by the Department of Mental Health have generated over 4,000 diversions and $11 million in savings since 2003.” Diane Gould Worcester Telegram February 2018

Dvoskin, J. (2018) Speaking of Psychology: Dispelling the myth of violence and mental illness Episode 27 American Psychological Association
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On Police Identification of the mentally abnormal

How to recognizeWestborough, MA March 28, 2018 The police-mental health interaction continues to be one that neither party exhibit great confidence nor take great pride in.  Myths abound about how to treat those so afflicted – especially among law enforcement personnel. I have provided classes for LEO’s and generally they are not well attended and tend to bore the average officer. In Maine, LEO’s are required to have regular training in working with the mentally ill in order to maintain their LEO credentials. Other states in New England have similar requirements and now focus on psychological first aid and deescalation protocols.  I have presented on topics of assessment of risk and dangerousness with some success.  In- service training must be short and to the point or students will quickly lose interest.
The photograph above shows the cover of a guide book first written in 1954 that was instructional for police officers.  It was written to teach the law enforcement officers of the day to recognize signs of mental illness then defined as “abnormal people”.  It was written by 2 Louisiana State University psychologists and first used by a police agencies in the late 1950’s.  I have been trying to find a copy of this early version that was re-published in 1979 and now costs over $100.  It was written because police officers needed training and experience identifying features of psychiatric emergency. This was thought to reduce the uncertainty, fear and confusion around handling these cases by providing education including signs and symptoms.
After nearly 60 years, law enforcement is not significantly closer to understanding the mentally ill than they were in 1954. A colleague police psychologist Leo Polizotti, Ph.D. has an original copy of this booklet although I have not seen it as yet.  Dr. Polizotti provides consultation to law enforcement, officer selection interviews, and teaches a proactive approach psychological resilience to police officers that can afford them greater career satisfaction, professionalism, and longevity. Dr. Polizotti is tasked with supporting officers who are exposed to the daily grind of violence, suicide, homelessness, and its cumulative impact on a cop’s personal narrative.  His model suggests a fundamental change in how police officers interpret their experiences over time and acceptance of what cannot change and healthy adaptation.  He is a great asset to the Central Massachusetts community and across New England and espouses a model of stress resistance through adaptation.
“In 1954, the National Association for Mental Health first issued the book “How To Recognize and Handle Abnormal People: A Manual for the Police Officer.” Included were techniques on dealing with all kinds of “abnormal persons,” from psychopaths, drug addicts, and the “mentally retarded” to civil protestors and those involved in family disturbances.”  Posted by David Pescovitz, 2015
Text from 1954 How To Recognize and Handle Abnormal People: A Manual for the Police Officer is provided below.  It points out many of the outward signs of disturbed thinking often an underlying feature of those with mental illness – in this case something called ideas of reference. These signs are common among persons with early paranoia and are sometimes missed – even by members of the immediate family. This is still a common symptom of mental illness today and is considered to be the prodrome to a more serious loss of contact with reality. Ultimately, it comes down to who is at more risk for violence?  And how can we be sure?
It takes a healthy and educated police officer to observe, understand, and control unpredictable situations. Officers are required to adapt to the demands of individual calls for service.  A colleague Dr. Leo Polizotti has identified a model for coping with the strain of police service.  He cites the importance of avoiding apathy, withdrawal and bitterness on the job.  “Understanding the 3 C’s of hardiness, Challenge / Commitment and Control will assist officers to manage stress more effectively, resulting in fewer emotional and medical problems. By viewing each new situation as a challenge, instead of a threat, you become committed to that challenge. You can readily see yourself in control and better able to deal with the situation. You will enhance your “hardiness” or resistance to stress” Polizotti, 2018.   
“He may think, for example, that announcements made over the radio have something to do with him personally. He may even hear his name mentioned. These are called ideas of reference which, of course, means that the patient thinks people are referring to him in one way or another. In the beginning, ideas of reference may occur only occasionally, but they gradually become the rule rather than the exception, and finally they may develop into definite delusions of persecution or grandeur.”
The list below are the signs of “abnormal persons” that are printed in the booklet published in 1954:
  • He shows big changes in his behavior.
  • He has strange /losses of memory, such as where he is or what day it is.
  • He thinks people are plotting against him, or has grand ideas about himself.
  • He talks to himself or hears voices.
  • He thinks people are watching him or talking about him.
  • He sees visions or smells strange odors or has peculiar tastes.
  • He has complaints of bodily ailments that are not possible.
  • He behaves in a way which is dangerous to himself or others.
Interestingly, the bullet points above remain accurate today with the understanding that too many individuals suffering with a major mental illness also have substance abuse/dependence.  It is this fact that confounds most LEO – mentally ill encounters.  “Beyond the rigors of police work, lie the demands of a personal life, specifically a wife or husband and children. Maintaining a healthy and happy family life is on its own a demanding responsibility. Add these powerful life stressors and demands to the burdens of police work and  an officer may begin to feel the weight upon his or her shoulders.” Polizotti, 2018.  Emotional and physical strength and endurance requires hardiness that comes from personal responsibility and comittment to excellence and peak performance.  Greater focus on sobriety – including opioid and alcohol dependence is essential. If this can be maintained mental illness may remit to the extent that subjects can remain in the community. Programs like A.A., N.A., and other 12-step groups are free and often afford subjects great support.  In most cities there are 12-step meetings every day morning, noon and night.  The problem is getting people to realize they have a problem.  Even airports hold A.A. meetings for travelers in need of the 12-steps. We are working on a replacement manual like the one cited in this post.


Polizotti, L. (2018) Personal Life Demands. Presentation – Direct Decision Institute.
How To Recognize and Handle Abnormal People: A Manual for the Police Officer (1954) Matthews, R. M.D. and Rowland, L. Ph.D. NATIONAL ASSOCIATION FOR MENTAL HEALTH, INC. 10 COLUMBUS CIRCLE, NEW YORK 19, N. Y.
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Public Awareness Needed for Meaningful Jail Diversion

teachinginprison

“If mental illness drives the violent behavior than all weapons and substance use must be carefully controlled and eliminated.” Sefton, 2017

Westborough, MA December 21, 2017 Jail diversion is a hot topic across the country even here in Massachusetts. Since July, 2017 the Massachusetts Legislature has passed sweeping changes in the Criminal Justice System.  Locally and across the country, the numbers of persons incarcerated for minor offenses and drug crimes has grown in some cases exponentially. Many of these individuals have mental illness or drug abuse in addition to their criminality. The interaction between poly-substance abuse or dependence and exacerbation of underlying mental health symptoms is complex and multifactorial. The interaction of the two is sometime lethal as reported by the Globe Spotlight team It is the focus of mental health advocates and criminal justice experts nationwide as it pertains to jail diversion, alternative restitution and reduced police use of force. In Massachusetts, there is a move away from mandatory minimum sentences for all drug crimes except for those involving the sale and distribution of narcotics. Arguably, the impact on behavioral functioning when persons are gripped with co-occurring illness, such as alcoholism, is a recurrent problem for law enforcement and first responders. I have written about the impact of co-occurring illness such as alcoholism on mental and behavioral health is previously published posts here on Word press Human Behavior (Sefton, 2017). It is difficult to uncover which comes first – the addiction or the diagnosed mental illness and yet these are inextricably linked in terms of the strain on public resources and health risk to those so afflicted. Why is this important?

The importance of treatment for substance dependence and mental illness cannot be understated as violent encounters between law enforcement and the mentally ill have been regularly sensationalized. The general public is looking for greater public safety while at the same time MH advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. The referral and treatment infrastructure needed to provide a continuum of care in this growing population is available in very few places across America.

Yet in places like Bexar County, Texas – including San Antonio and 21 other towns or cities – the county jail population has dropped by over 20 percent as a result of crisis intervention training for police officers and mobile mental health teams to intervene with those in crisis. I have seen this for myself during a visit with the San Antonio Police Department where I rode with two members of the Mental Health Unit – Officers Ernest Stevens and Joseph Smarro. These men are exemplary in their assessment and intervention skill for keeping identified subjects off radar screens and out of the revolving door of the county jail.  It takes ongoing training, medical and psychiatric infrastructure, community compassion, and active engagement with members of the community to fly under the radar and effectively reduce the jail population. When necessary those most in need must have 24-hour availability for detoxification, emergency mental health, and access to basic needs such as food, clothing, and medicine. In San Antonio, they offer so much more including pre-employment training, extended housing, interview preparation including clothes, and opportunity for jobs.

The unpredictability of behavior by those who carry a “dual” diagnosis has emerged as a confounding factor in the criminal justice system raising the specter of frustration over the limitations within the system. Jail diversion programs and treatment options are needed in order to retain public safety goals and provide for needs of the mentally ill and substance dependent. In Massachusetts, cities and towns are grappling with how best to intervene with the mentally ill in terms of alternative restitution for drug-related misdemeanor crimes in lieu of mandatory jail sentences that many crimes currently require. The Massachusetts legislature has taken up Criminal Justice Reform and passed a bill in late 2017 making changes in the mandatory minimum sentencing laws.  Some believe, as much as 20-40 percent of all incarcerated persons suffer with mental health diagnoses and are not getting the treatment they require. To provide a bare bones system would add billions to state and federal dollars spent on the needs of inmates at a time when measurable outcomes for in house care are limited.

In my practice, I see many cases of co-occurring pain syndromes with other physical debilities such as stroke or traumatic brain injury. Some of these cases are substance dependent and live lonely, chaotic lives.  Generally the emotional impact of two or more diagnosed illnesses yields a greatly reduced capacity for adaptive coping and puts a great stress on the individual system. The importance of addressing co-occurring substance abuse or dependence is now well recognized and with treatment can result in healthy decision-making, growth in maturity, and greater self-awareness. If legislators have a serious desire to reduce statewide numbers of incarcerated persons a comprehensive plan must be considered for both pre-arrest and post-arrest. Programs greater understanding of addiction and added treatment options must be explored through a joint public and private initiative.

Mental and Physical Health Screening

At time of arrest the individual must have some level of mental health assessment if mental illness is suspected or documented. When I was a police officer prior to 2015 we often asked the D.A. to provide a court clinic assessment of the suspect to rule out suicidal ideation or delusional thinking. This must also include a screening for dangerousness especially when a subject is arrested for intimate partner abuse. Next a health history questionnaire should be undertaken to screen for co-occurring illness – both physical and mental. If a diabetic suspect is held without access to his insulin he is at great risk of death from stroke. Similarly, a person arrested for assault who suffers from paranoid ideation is at greater risk of acting violently without access to psychiatric medication. Finally, an alcoholic brought to the jail with a blood alcohol level greater than 250 is at great risk for seizures and cardiac arrhythmias when delirium tremens begin 6-8 hours after his last drink. The risk to personal health in each of the scenarios above must be taken seriously and the obtained data should be factually corroborated. Police departments across the United States are pairing up with private agencies to provide in-house evaluation and follow-up of individuals who fall on the borderline and may not be easily assessed by the officer in the field.

Diversion Safety Plan with Mandated Revocation

Next, the probation and parole department must obtain an accurate legal history prior to consideration for bail. A nationwide screen for warrants and criminal history based on previous addresses is essential. In many places these are being done routinely. In the case of someone being arrested for domestic violence he may have no convictions thus no finding of criminal history. For these individuals the dangerousness assessment may bring forth red flag data needed for greater public safety resulting in protection from abuse orders, mandated psychotherapy, and in some cases, no bail confinement when indicated. Releasing the person arrested for domestic violence without a viable safety plan increases the risk to the victim and her family, as well as the general public – including members of law enforcement.

Bail, Confinement, Mandated Treatment

There is some thinking that higher amounts of bail may lessen the proclivity of some offenders to breach the orders of protection drafted to protect victims and should result in revocation of bail and immediate incarceration when these occur. Mandated treatment may be more successful when legal charges are held as leverage where after 6 months of sober living and regular attendance at 12-step recovery meetings charges can be dismissed or modified to each individual case.  This takes a complete overhaul of the front end of criminal justice system and requires buy-in by judges, district attorneys, and individual family members.

When it comes lack of compliance and repeated domestic violence, I have proposed a mandatory DV Abuse Registry that may be accessed by law enforcement to uncover the secret past of men who would control and abuse their intimate partners. This database would also include information on the number of active restraining orders and the expected offender’s response to the “stay away” order. In cases where the victim decides to drop charges there should be a mandatory waiting period of 90 days. During this waiting period the couple may cohabitate but the perpetrator must be attending a weekly program of restorative justice therapy, 12-step recovery and substance abuse education. Violations of these court ordered services are tantamount to violation of the original protection order (still in place) and victim safety plan and may result in revocation of bail. If the waiting period passes and the perpetrator has met the conditions of his bail than he may undergo an “exit” interview to determine whether or not the protection order / jail diversion plan may be extended or whether he/she has met all requirements.  In any case further police encounters will be scrutinized and prior charges may be re-instated or filed as needed.

Michael Sefton


Sefton, M. (2017) Human Behavior Blogpost: https://msefton.wordpress.com/2017/03/30/police-are-building-bridges-and-throwing-life-savers/ taken December 10, 2017

Jail Diversion: Reduced costs by spending more on mental health

PART 1

WESTBOROUGH, MA July 6, 2017 Jail diversion is a hot topic across the country. The numbers of persons incarcerated for minor offenses and drug crimes has grown. Many of these individuals have mental illness or drug abuse in addition to their criminality. The interaction between poly-substance abuse or dependence and exacerbation of underlying mental health symptoms is complex. It is the focus of mental health advocates and criminal justice experts nationwide as it pertains to jail diversion and reduced use of force among law enforcement.  In Massachusetts, there is a move away from mandatory minimum sentences for all drug crimes except for those involving the distribution of narcotics. Arguably, the impact on behavioral functioning when persons are gripped with co-occurring illness is a recurrent problem for law enforcement and first responders. I have written about the impact of co-occurring illness such as alcoholism on mental and behavioral health is previously published posts here on Word press Human Behavior (Sefton, 2017). It is difficult to uncover which comes first – the addiction or the diagnosed mental illness and yet they are inextricably linked in terms of the strain on public resources and health risk to those so afflicted. Why is this important?

The importance of treatment for substance dependence and mental illness cannot be understated as violent encounters between law enforcement and the mentally ill have been regularly sensationalized. The general public is looking for greater public safety while at the same time MH advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. The referral infrastructure to provide a continuum of care in this growing population is available in very few places across America.

Models of Care

Yet in places like Bexar County, Texas the county jail population has dropped by over 20 percent as a result of crisis intervention training for police officers and mobile mental health teams to intervene with those in crisis. I have seen this for myself during a visit with the San Antonio Police Department where I rode with two members of the Mental Health Unit – Officers Ernest Stevens and Joseph Smarro. It takes training, medical and psychiatric infrastructure, community compassion, and active engagement with members of the community often left to fly under the radar to effectively reduce the jail population. When necessary those most in need must have 24-hour availability for detoxification, emergency mental health, and access to basic needs such as food, clothing, and medicine. In San Antonio they offer so much more including pre-employment training, extended housing, interview preparation including clothes, and opportunity for jobs.

Behavioral Analysis and Law Enforcement

The unpredictability of behavior in those who carry a “dual” diagnosis has emerged in the criminal justice system when jail diversion programs and treatment options are brought forth raising the specter of frustration over the limitations within the system. Cities everywhere are grappling with how best to intervene with the mentally ill in terms of alternative restitution for drug-related misdemeanor crimes in lieu of mandatory jail sentences that many crimes currently require. Some believe, as much as 20-40 percent of all incarcerated persons suffer with mental health diagnoses and are not getting the treatment they require. To provide a bare bones system would add billions to state and federal dollars spent on the needs of inmates at a time when measurable outcomes for in house care are limited.

In my practice I see many cases of co-occurring pain syndromes with other physical debility such as stroke or traumatic brain injury. Generally the emotional impact of two or more diagnosed illnesses yields a greatly reduced capacity for adaptive coping and puts a great stress on the individual system. The importance of addressing co-occurring substance abuse or dependence is now well recognized and with treatment can result in healthy decision-making, growth in maturity, and greater self-awareness. If legislators have a serious desire to reduce statewide numbers of incarcerated persons a comprehensive plan must be considered for both pre-arrest and post-arrest. Infrastructure for enhanced understanding of addiction and greater treatment options must be explored through a joint public and private initiative.

PROPOSED JAIL DIVERSION INITIATIVE

PRE-ARREST JAIL DIVERSION – No crime committed

If police encounter subjects with a known history of mental illness through their community policing efforts they should return the subject to his family or primary psychiatric caregiver – this might be a physician, physician’s assistant (PA), a nurse practitioner (NP), even a psychologist for immediate crisis intervention. Depending upon the nature of the police encounter such as during the nighttime hours the subject may be transported to a local emergency department for psychiatric evaluation. This model has grown less popular because of the growing wait times in local hospital emergency departments – especially for those suspected of mental illness and tends to make them increasingly agitated. Persons with mental illness are often homeless and come into police contact simply on the basis of panhandling or looking suspicious and out of place in the neighborhood. Often they are reported to police because they are talking to themselves, suspicious, and menacing toward pedestrians making them afraid.

The hospital alternative might be to establish regional psychiatric emergency intake centers available 24-hours daily. At one point states had regional hospitals that have been closed down releasing thousands of institutionalized patients into the community. The plan for de-institutionalization was to provide a neighborhood center at which the patient could continue his or her treatment and receive their needed medication to keep them symptom free.

Minor crime committed

When a crime is committed by someone with known or suspected mental illness such as simple assault, disorderly conduct, or shoplifting the responding police officer’s will have discretion whether to bring forth charges or not in exchange for an alternative disposition that would defer jail time. These are not new concepts. Law enforcement has always had the discretion to arrest or not arrest for many minor offenses. The choice often comes down to the subject demeanor and his response to police officer directives at the time of the encounter. In some cases an officer must arrest such as in the setting of domestic violence, child abuse, or as a result of a felony being committed.

In these cases charges may be brought and held as long as the subject entered treatment or remained abstinent from use of drugs or alcohol – the jail diversion plan. If they failed to follow the terms of their diversion plan the charges would be re-instated and sent to district attorney for prosecution.  The alternative is a revolving door of addiction and petty crime that, at times, will escalate into violent crime. As a society more can be done to reduce criminality and jail diversion through empathic, sensitive treatment options.