Inter-Agency Approach to Dealing with Mentally Disordered People in the Community

Today I received a comment on my blog “Dealing Safely With Emotionally Disturbed People” from Frank, who wrote:

“You will see on my link that there is a very dangerous woman who is loose in our town who has severe mental illness. She has jumped people, stabbed people, threatened her mother, but she still manages to sneak by the cops and denies treatment. Right now she is homeless and could be anywhere hiding out, ready to pick fights with people. I have posted as many flyers, video warnings, what else can I do? The cops can’t do anything.”

I am surprised to hear that the police can’t deal with this problem. Dealing with mentally disordered people in the community is an issue all law enforcement agencies face. So I thought that I’d mention two systems developed by police to deal with such situations. First of all, here are some statistics:

 

Approximately 5% of the US population has a serious mental illness(1). The US Department of Justice reports that about 16% of the population in prison or jail has a mental illness(2). A study conducted in New York State found that men involved in the public mental health system over a five-year period were four times as likely to be incarcerated as men in the general population; for women the ratio was six to one(3).  The Los Angeles County Jail, the Cook County Jail (Chicago) and Riker’s Island (New York City) each hold more people with mental illness on any given day than any hospital in the United States(4). Inmates with mental illness in state prison were 2.5 times as likely to have been homeless in the year preceding their arrest than inmates without a mental illness(5).

 

Given the enormity of the problem, almost half of the states in the US have established special commissions or task forces to look into some aspect of their mental health systems in the last four years(6). Legislation calling for the establishment of such bodies has been introduced in an additional five states. Almost half of these commissions are explicitly charged with investigating the criminalization of mental illness(7). One of the approaches is for law enforcement agencies to enter into cooperative efforts with mental health treatment facilities.

 

One effective model for dealing with this situation was developed by the Memphis Police Department.  They found that their officers were getting stuck for 4-6 hours at the medical center for mental health admissions. That’s enough to discourage any police officer from becoming involved in mental health investigations. Once Memphis implemented their Crisis Intervention Team (CIT) model, these hospital waits were cut down to 15 minutes. The CIT model has the police agency train specially designated patrol officers to respond to mental health issues, and uses them to respond to calls involving these issues. Shortly after the CIT implementation, Memphis discovered that injuries suffered by individuals with mental illness who got into violent confrontations with police decreased by nearly 40%(8). The Albuquerque PD, which also adopted the CIT model, reports that there was a reduction of 10% in the number of mentally ill going to jail with whom their police had contact, and they were able to decrease using their SWAT team by 58%. Injuries were reduced to just over 1%(9).

 

The police department that I worked for, Vancouver PD, created the other response model in 1977. It started as an informal arrangement involving front line community mental health workers using pagers to provide an after-hours service to meet the needs of the community and police. This eventually evolved into the Vancouver Mental Health Emergency Services (MHES) unit that I worked for. In 1984 this was expanded on a trial basis as a partnership between MHES (now part of the Vancouver Coastal Health Authority) and the Vancouver Police Department. Unlike the Memphis Police Department’s CIT model, VPD and MHES created a partnership consisting of a psychiatric nurse teamed up with a police officer in a unit called Car 87. This partnership proved very successful and was formalized in 1987. MHES/Car 87 has access to an on-call physician available for consultation or call out for on-site assessments. 

 

The goal of MHES/Car 87 is to provide rapid response to mental health emergencies while minimizing admissions to hospital emergency departments. The MHES/Car 87 program aims to provide the least intrusive resolution to an emergency while maintaining the safety of mentally ill persons and the public. Our approach is to treat people with mental illnesses within their own community. Early intervention often reduces unnecessary admissions to hospital and can lead to a better over all prognosis for the course of a person’s mental illness. In 2002 MHES logged approximately 13,000 calls, leading to approximately 1,850 outreach calls, resulting in 382 hospitalizations. 

 

The current Vancouver MHES program includes a 24-hour crisis line, a geriatric nursing team, and MHES response for day shift and afternoon shift 7 days a week.

 

The strength of this unique inter-agency collaboration comes from the ability to share information between the two agencies and the way in which the legislated powers of the police officer and nurse/physician complement one another. Car 87 vehicles contain all of the special equipment (first aid kit, medical bag, medications, protective clothing, masks and goggles, WRAP restraining device, crime scene tape, etc.) necessary for them to perform their psychiatric assessments and apprehensions. The Car 87 nurse is equipped with body armor, an identification jacket marked “Nurse”, a portable radio and spare keys for the police vehicle. This permits the nurse to communicate in emergency situations and allows the nurse to drive the police car to hospital when the police officer is required to escort an apprehended client to hospital in the ambulance. 

 

The role of the Car 87 partnership is to determine the risk associated with apparent mental disorders and provide the most appropriate intervention. The police officer and nurse partnership in MHES/Car 87 works to provide the least intrusive resolution to a mental health emergency while maintaining the safety and rights of mentally ill persons and the public. The police officer assigned to Car 87 is there to exercise their authority under the Mental Health Act, conduct criminal investigations (if applicable), and to manage violence. The psychiatric nurse is there to do psychiatric assessments, interpret the mental health collateral information and provide liaison with the on-call psychiatrist. This partnership determines the most appropriate course of action for each mental health call. 

 

The Car 87 police officer has the authority under the Mental Health Act to apprehend people suffering from an obvious mental disorder who are endangering themselves or others. This is often the easiest way to get a mentally ill person into treatment.  The police officer has legal authority to force entry to a residence in emergency situations. Of course this officer has access to force options and resources to adequately contain and safely apprehend unstable and violent clients. 

 

The nurse assigned to Car 87 is responsible for conducting mental health and medical assessments, and acts as a resource to other police officers with regards to mental health issues. The nurse in Car 87 has access to an on-call psychiatrist who can attend to assess the client and certify them if necessary. As the Car 87 team has basic medical equipment and some medications with them, it is also possible for the nurse to consult with the on-call physician and stabilize the client on scene by administering medications. Thus in some cases it is not necessary to bring the client into a medical facility for immediate treatment. Follow up with the client’s Mental Health Team can be conducted the following day instead.

 

In the case of a disagreement between the police officer in Car 87 and the MHES nurse assigned to the car over the proper course of action to deal with a particular mental health assessment, they can consult with the duty doctor as to the best course of action.

 

Car 87 responds to requests for service from dispatch or police units in the field. Police units encountering people possibly suffering from mental illness in the course of their duties will forward reports electronically to Car 87 for review and possible follow up. The local Mental Health Teams forward alerts on clients of concern to them to Car 87 as well. This allows the Car 87 team to come up with a tentative action plan at the beginning of their shift. The police officer and nurse enter their reports electronically in their respective systems at the end of shift so that the agencies referring the calls can see what action has been taken the following day. This is also useful in that some mentally ill people tend to be paranoid and litigious: proper documentation makes such situations easier to deal with.

 

Through such inter-agency cooperation problems with mentally disordered individuals can be identified and addressed quickly, leading to a better prognosis for treatment. 

 

1) R. C. Kessler et al., “A Methodology for Estimating the 12-Month Prevalence of Serious Mental Illness,” In Mental Health United States 1999, edited by R.W. Manderscheid and M.J. Henderson, Rockville, MD, Center for Mental Health Services

2)  Paula.M. Ditton, Mental Health Treatment of Inmates and Probationers, Washington DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, July 1999.

3)  Judith F. Cox, Pamela C. Morschauser, Steven Banks, James L. Stone, “A Five-Year Population Study of Persons Involved in the Mental Health and Local Correctional Systems,” Journal of Behavioral Health Services & Research 28:2, May 2001, pp. 177-87.

4)  E. Fuller Torrey, “Reinventing Mental Health Care,” City Journal 9:4, Autumn 1999.

5)  Ditton, Mental Health and Treatment.

6)  See http://www.csgeast.org/programs/criminal_justice/statewide_commissions.htm

7)  Ibid.

8)  B. Vickers, “Memphis, Tennessee Police Department’s Crisis Intervention Team,” Bulletin from the Field, Practitioner Perspectives, U.S. Department of Justice, Bureau of Justice Assistance, Available at: www.ncjrs.org/pdffiles1/bja/182501.pdf.

9)  Ibid.