Download now MH - The Justice Academy

Mental Health Officer
Curriculum
Course 4001
Texas Commission on Law Enforcement
Officer Standards and Education
June 2008
Mental Health Peace Officer
Page 1 of 97
June 2008
Mental Health Officer
Curriculum
#4001
Abstract
The purpose of the Mental Health Officer course is to further inform and educate the
officer in the area of mental health and issues pertaining to serving as a mental health
officer, to include advanced crisis intervention training.
The Legislature in 1993 in H.B. 771 (Naishtat & Madla) Attachment of SB 292 (Rosson)
established a goal in Section 531.00(g) Health and Safety Code of at least one special
officer for mental health assignment in each county and requires mental health mental
retardation authorities to assist local law enforcement agencies in their desire to certify
such officers. It allows the Commission in Section 415.037, Government Code to certify
officers; issue achievement or proficiency certificates and establish rules for training,
testing, and certification. It adds the special officer to the list of persons who can
transport committed individuals to a mental health facility. It also states that an individual
with a mental illness cannot be transported with a prisoner and cannot be physically
restrained during transportation except in an emergency. (If restraining is used, the
restraint and length of time must be documented and the documentation left at the facility
where the individual is transferred).
The Legislature in 1993 in S.B. 1067 (Whitmire) included an amendment to the Code of
Criminal Procedure Article 16.22. The article requires a magistrate to order the
examination of, and transfer to, the nearest appropriate mental health facility, and a
defendant committed to the custody of a peace officer, if a peace officer provides
evidence that the defendant is a person with mental illness.
Senate Bill 1473 amended 1701.253, Occupations Code, by requiring training in “deescalation and crisis intervention techniques to facilitate interaction with persons with
mental impairments.” Effective September 1, 2005, this training became a requirement
for an intermediate or advanced certificate, and a person licensed as a peace officer for
more than two years, or holding an intermediate or higher certification, must complete
CIT training prior to September 1, 2009. Beginning January 2005, Basic Crisis
Intervention Training was also inserted into the Basic Peace Officer Course so all officers
would complete this training at the academy level. The attached course (4001) builds on
Chapter 27 Crisis Intervention/Mental Health Code of the Basic Peace Officer
Curriculum through review and a continuation of concepts.
This Instructor Outline is designed to assist the instructor in developing appropriate
lesson plans to teach the information necessary to address the TCLEOSE mandated
Mental Health Peace Officer
Page 2 of 97
June 2008
course learning objectives (HB 771, Section 415.037) required for successful student
completion.
It is the responsibility of the coordinator to ensure that copies of this curriculum
and their departmentally created lesson plans are up to date and on file at your
individual departments or academies.
Target Population: Texas Law Enforcement Officers
Prerequisites for class participation:
 Completion of Basic Crisis Intervention Training, Course # 3841 or 3842; or
Basic Peace Officer Course 1000 after January 2005.
Prerequisites for Mental Health Officer Proficiency Certification:
 Currently appointed as a peace officer or justice of the peace;
 At least two years experience as a peace officer or justice of the peace;
 If not currently a commissioned peace officer, an applicant must meet the current
enrollment standards;
 If an applicant is a commissioned peace officer, an applicant must not ever have
had a license or certificate issued by the commission suspended or revoked;
 If an applicant is a commissioned peace officer, an applicant must have met the
continuing education requirements for the previous training cycle;
 Successful completion of a training course in emergency first aid and lifesaving
techniques (Red Cross or equivalent); and
 Successful completion of the current mental health peace officer training course
and pass the approved examination for mental health officer proficiency, with a
score of 80% or better.
Instructor Qualifications: Instructors for this course should be TCLEOSE certified
instructors and currently a TCLEOSE Mental Health Peace Officer.
Length of Time for Course: Minimum of 40 hours
Facility Requirements: Standard classroom environment
Evaluation Process and Procedures: Classroom interaction with instructor and students,
oral and written participation through role-play and discussion as well as a legislatively
mandated written test. This test is to be obtained through Texas Commission on Law
Enforcement Officer Standards and Education, Education and Programs Division. A
passing score of 80% is required and may only be retaken at the discretion of instructor
via documented academy guidelines.
Reference Materials: See instructor resource guide.
Note to Coordinator/Instructor: Guest presenters are a highly recommended for this
course due to the highly specialized context of this course. Guest speakers will need to be
Mental Health Peace Officer
Page 3 of 97
June 2008
contacted and scheduled by the sponsoring academy. These speakers may include but are
not limited to: MHMR representative and Mental Health professionals, consumer and
consumers family, subject matter experts, and persons with role-play experience for
authenticity in scenarios.
Mental Health Peace Officer
Page 4 of 97
June 2008
Mental Health Peace Officer Curriculum:
Unit Goal: 1.0. To sensitize officer to the adversity of mental illness.
According to the 2004 U.S. Census, approximately 26.2% of the U.S. adult population,
totaling 57.7 million people (about 1 in 4 adults) had a diagnosable mental disorder
within the last year. Further statistics dictate that 1 in 17 or 6% of these individuals suffer
from a serious mental illness, with 45% of this category reporting a diagnosis of two or
more disorders. Mental illness has become the leading cause of disabilities in ages 15-44.
However, this remains an understatement of the number of persons with mental health
problems. Many people do not seek treatment and thus are not recorded in statistical
records. The following table references the above mentioned U.S. Census statistics:
Disorder
Mood Disorder
Major Depressive
Disorder
Bipolar Disorder
Schizophrenia
Anxiety Disorder
Panic Disorder
Obsessive
Compulsive
Disorder
Post Traumatic
Stress Disorder
Autism
Percentage of
Population
9.5
6.7
Converted to
Millions
20.9
14.8
Median Age of
On-set
30
32
2.6
1.1
18.1
2.7
1.0
5.7
2.4
40
6
2.2
25
20 to early 30’s
21.5
24
19
3.5
7.7
23
3.4 per 1000
children
3-10
Reference: National Institute of Mental Health (http://www.nimh.nih.gov)
A study completed by Dr. Ronald C. Kessler, Harvard University further indicates that up
to 55% of U.S. adults suffer from some sort of mental illness within their lifetime.
Four important factors strongly affect the current mental health situation in America.
Theses factors include:
 Deinstitutionalization
 Criminalization
 Medicalization
 Privatization
Deinstitutionalization is an important event that occurred most predominantly after the
1960’s. Public attitudes, laws, and professional mental health practices changed leading
to the closing of the majority of the states State Hospitals, psychiatric hospitals, and
insane asylums. Society shifted in its preference of housing for persons diagnosed with a
mental illness. This shift released persons from these previously mentioned institutions
Mental Health Peace Officer
Page 5 of 97
June 2008
and referred them to community-based mental health services. The problem with this
shift was that adequate community-based services were never provided. In fact these
idealized services, even today, are not a reality and have led to failure in treatment in
many mental health arenas.
Criminalization has become a direct result of deinstitutionalization. As a result of the
break down in community services for newly released individuals, law enforcement
offices have been bombarded with calls concerning the mentally ill individual.
Traditionally police have handled these calls informally, but with increased visibility,
continued community complaints, and “petty” crimes turning to more severe crimes law
enforcement officers are challenged with what to do next. They in turn are finding
resources limited and arrest the most available solution to the immediate problem. The
mentally ill individual now find themselves in the midst of criminalization and reinstitutionalization once again. This time however, in jails and prisons instead of state
hospitals and psychiatric facilities.
Medicationization is an evolution which found its roots in electric shock treatment and
psychotherapy. Medications have now become a constant in mental health treatment and
a need in the realm of community-based resources. The challenge now however, has
become how to get non-institutionalized individuals to take these medications as
prescribed.
Privatization comes into play as many community-based facilities become funded and
operated by private companies and individuals, with an inherent incentive to keep
expenses to a minimum. This incentive translating into a minimum and low- paid staff
relying on law enforcement to assist in managing its patients. This situation resulting in
wasted police resources and individuals with a mental illness not receiving the quality
care they deserve.
Thus, Law Enforcement as well as Correctional Officers frequently encounter persons
with a mental illness. Collaborated statistics show:



10-15% of jailed persons have a severe mental illness
An estimated 7% of police contacts in jurisdictions with 100,000 or more people
involve the mentally ill
A three-city study found that 92% of patrol officers had at least one encounter
with a mentally ill person in crisis in the previous month, and officers averaged
six such encounters per month
Officers encounter persons with a mental illness in a variety of situational circumstances
to include: criminal offenders, disorderly conduct, missing persons, complainants,
victims, and persons in need of assistance. According to one Texas study, the most
frequent scenarios are:
 Calls from a family member or friend requesting police assistance during a
psychiatric emergency.
 An individual with a mental illness feeling suicidal and calls police for help.
Mental Health Peace Officer
Page 6 of 97
June 2008



Police encounters a person with a mental illness who is behaving inappropriately
in public.
Citizens call police when they are uncomfortable during an encounter with a
mentally ill person perceiving the individual as threatening or dangerous.
A person with a mental illness personally calls as a result of an imagined threat.
There is a tendency to simply define people with a mental illness as the problem and
getting them out of sight as the solution. Be careful not to blame the person, but instead
focus on the behavior. This is a medical condition.
“Most days she walks up and down the sidewalks of North Waco, stopping every few
steps to scream at the unintelligible voices taunting her mind. By the afternoon, she often
has found a few dollars to buy some cheap booze to help her self-medicate and escape the
accusations of the invisible demons. Day in and day out, the living hell continues with
little or no real relief, while many only gawk or ridicule. Almost one of every five
persons in America suffers from severe mental illness. Yet most of us know little about
the diseases or how to help those struggling or those who care for them. Major
depression, bipolar disorder, schizophrenia, panic disorder, post-traumatic stress disorder
and borderline personality disorder are some of the diagnoses. Each disrupts a person’s
ability to function adequately, affecting one’s ability to relate to others, shredding his or
her coping skills. Mental illnesses are not the result of personal weakness, or lack of
character or poor upbringing. They are medical conditions. These illnesses are
particularly hard on those who are poor and lack support systems.”
Instructor Note:
This excerpt is from the Waco Tribune-Herald (4-4-2-2008) and written by Jimmy
Dorrell, Director Mission Waco, Board of Contributors: “Their demons, our
obligations”.
According to the National Alliance on Mental Illness (NAMI), “…the good news about
mental illness is that recovery and help really are possible. Most people diagnosed with a
serious mental illness can experience relief from their symptoms with treatment and
individual case management. Yet Texas now ranks near the bottom of the nation with
funds to provide this treatment. Local MHMR centers are doing more and more with less
and less. The system is crumbling under the load.”
1.1. Define the term “mental illness.”
There is not one standard definition of mental illness. It is instead a term used to describe
a variety of conditions which appear to influence a person’s behavior and/or how the
person perceives the world. The definition may focus on personality, behavior, or organic
conditions dependent on the nature and category of interest, i.e., medical doctors,
research scientists, psychiatrists, psychologists, law enforcement, or social workers.
General Definition:
Mental Health Peace Officer
Page 7 of 97
June 2008
Illness, disease, or condition that either substantially impacts a person’s thought,
perception of reality, emotional process, or judgment, or grossly impairs a person’s
behavior, as manifested by recent disturbance behavior.
Professional Definition of Mental Illness:
“Mental Illness is a biopsychosocial brain disorder characterized by dysfunctional
thoughts, feelings, and/or behaviors that meet DSM-IV diagnostic criteria.” (Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric
Association, Updated, 1999) Mental Illness is diagnosed based on these behaviors and
thinking as evaluated by a Psychiatrist, Psychologist, Licensed Professional Counselor,
Licensed Social Worker, or other qualified professional.
Insanity (Legal Term):
Insanity is considered a diminished capacity and inability to tell right from wrong. This
is not a psychological term. The definition varies from state to state. It is generally used
by the court with regard to an individual’s competency to stand trial.
Abnormal Versus Normal Behavior:
A sharp dividing line between “normal” and “abnormal” behavior does not exist.
Adjustment seems to follow what is called a “normal distribution,” with most people
clustered around the center and the rest spreading out toward the extremes.
Instructor Note:
Illustrate this distribution on whiteboard or flip-chart for further clarification and
discussion.
1.2. List three categories of mental illness most predominately identified with
disease severity
Prominent examples of serious mental illness are identified as:
1. Psychotic Disorder: All cases of schizophrenia
2. Mood Disorder: Severe cases of major depression and bipolar disorder
3. Anxiety Disorder: Severe cases of generalized anxiety disorder, obsessivecompulsive disorder, and post-traumatic stress disorder
Other less severe disorders that will be reviewed in this curriculum will include:
1. Cognitive Disorders (Alzheimer’s, Substance Abuse)
2. Personality Disorders (Paranoid, anti-social)
3. Disorders first diagnosed in infancy, childhood or adolescence (Autism, Mental
Retardation, Attention Deficit Hyperactivity Disorder)
1.3. Define terms associated with a Psychotic Disorder
Definition of Psychosis:
“A group of serious and often debilitating mental disorders that may be of organic or
psychological origin and are characterized by some or all of the following symptoms:
Mental Health Peace Officer
Page 8 of 97
June 2008
impaired thinking and reasoning ability, perceptual distortions, inappropriate emotional
responses, inappropriate affect, regressive behavior, reduced impulse control and
impaired reasoning of reality.” (Social Work Dictionary, 2nd Edition, by Robert L. Baker)
Psychosis is an illness involving a distortion of reality that may be accompanied by
delusions and/or hallucinations. The person may be hearing voices, he may look at a
person and see a demon, he may think people are after him, or he may consider himself
Jesus Christ. To the person, these hallucinations and delusions are REAL. These are most
commonly seen in persons with Schizophrenia, Bipolar Disorder, Severe Depression or
Drug Induced Disorders. Physical circumstances can also induce a psychotic state. These
conditions could include: organic brain disorders (brain injury, infections to brain, or
Alzheimer’s disease), electrolyte disorder, pain syndromes, and drug withdrawal.
Definition of Delusion:
False beliefs not based on factual information. A delusion implies belief in something
that is contrary to fact or reality, resulting from deception, a misconception, or a mental
disorder. A persistent belief maintained in spite of evidence to the contrary.
Definition of Hallucinations:
Distortions in the senses where the individual experiences auditory sounds and/or visual
images that are technically not there. Poor processing of information and illogical
thinking can then result in disorganized and rambling speech and/or delusions. It is not
uncommon for a person hearing voices to hear two or more at a time. If you approach a
person and start yelling at him, you are only adding to the person’s confusion. Imagine
having two or three people shouting at you all at once while an officer is trying to give
you directions.
The voices are almost always negative, commanding and insulting; telling the person
things like “Die, die, die”,” Kill yourself”, “You’re no good”, or “They are going to get
you”. These voices are real to the person experiencing this episode. Researchers have
conducted brain scans on persons hearing voices during a psychotic episode. Brain
imaging studies have found that parts of the temporal lobe activates during
hallucinations. This is the same part of the brain that is activated when you are listening
to the instructor’s voice. Auditory hallucinations reportedly sound like they’re coming
from outside of your head and until you come to understand what they are; you cannot
distinguish them from someone actually talking to you.
Common symptoms experienced by persons during a psychotic episode:
 Hearing voices
 Feelings of paranoia
 Visual hallucinations
 Heightening of the senses
Behavioral cues of persons with a psychosis:
 Inappropriate or bizarre dress
 Lethargic or sluggish body movements
Mental Health Peace Officer
Page 9 of 97
June 2008





Impulsive or repetitious body movements
Responding to hallucinations
Causing injury to self
Home environment: strange decorations (aluminum on windows), pictures turned
over, waste matter/trash on floors and walls.
Unusual attachment to childish objects or toys
Emotional cues of persons with a psychosis:
 Lack of emotional response
 Extreme or inappropriate sadness
 Inappropriate emotional reactions
1.3.1. Discuss Schizophrenia and its relationship with Psychotic Disorders
Schizophrenia:
Schizophrenia consists of a group of psychotic disorders characterized by changes in
perception. These disorders cause an over sensitivity to sounds and visions characterized
by hallucination and/or impaired distorted thinking. It is considered the most chronic and
disabling of severe mental illnesses, typically emerging in teenagers and young people.
Statistical Facts:
 In the US, approximately 2.4 million adults, age 18 and older in a given year are
diagnosed with schizophrenia.
 Worldwide statistics remain fairly consistent with US figures.
 Ranks among the top 10 causes of disability in developed countries worldwide.
 High risk of suicide. Approximately 10% of people with schizophrenia commit
suicide.
Distorted thinking results in:
 Hallucinations
 Poor processing of information/Attention Deficit
 Illogical thinking that can result in disorganized and rambling speech, and/or
delusions.
Changes in Emotion:
 May overreact to situations
 Have “flat affect”: Decreased emotional expressiveness, diminished facial
expression and apathetic appearance.
 Anhedonia: Lacking pleasure or interest in activities that were once enjoyable.
 Withdrawn: Media tends to portray as violent this is rarely the case.
Note to the instructor: See ABC News Home Video “Schizophrenia,” a 20/20 episode
from 2/25/00
Mental Health Peace Officer
Page 10 of 97
June 2008
1.4. Discuss the characteristics of a Mood Disorders
Definition: A mood disorder is a mental health disorder with an abnormal mood as its
primary feature. “Mood” refers to the sustained feelings and emotions through which a
person interprets life. Most mood disorders are defined and diagnosed by the occurrence
of one or more mood episodes, or periods of abnormal happiness or sadness.
A mood disorder is another type of mental illness occurring in approximately 20 million
Americans over the age of eighteen in a given year. It is demonstrated by disturbances in
one’s emotional reactions and feelings. Recognizable behaviors that are associated with
mood disorders could include: lack of interest and pleasure in activities, extreme and
rapid mood swings, impaired judgment, explosive temper, increased spending and
delusions. These disorders also referred to as Affect Disorders, also involve persistent
feelings of sadness, periods of feeling overly happy, or fluctuations in the two extremes.
Causes: Researchers believe (SAMHSA) that a complex imbalance in the brain’s
chemical activity plays a prominent role of mental illness selectivity in the individual.
Brain chemicals called neurotransmitters convey messages between the nerves.
Abnormalities in the regulation of these neurotransmitters, particularly norepinephrine,
serotonin and dopamine, are believed to cause the alterations in mood.
Mood disorders also appear to be linked with genetics. Individuals who have relatives
with a history of a mood disorder are at a higher risk of development. Some researchers
also believe that individuals may have inherited a tendency to have a mood disorder that
can also be triggered by environmental factors. These environmental factors can also
buffer against the onset.
Gender is also a major risk factor for development of a mood disorder. According to the
National Institute of Mental Health (NIMH), women have nearly twice as much risk than
men. Many researchers report the belief of hormonal changes associated with menstrual
cycle, pregnancy, and menopause as being key factors.
The two most common Mood Disorders are considered Major Depressive Disorder and
Bipolar Disorder.
1.4.1. Discuss Major Depressive Disorder
Most people have experienced some form of depression in their lifetime or have even had
repeated bouts with depression. It is considered a natural reaction to trauma, loss, death
or change.
Major depression is however, not just a bad mood or feeling of being “blue.” It is a
disorder that severely affects an individuals thinking and behavior. It is defined as a
depressed mood or loss of interest of at least two weeks duration, accompanied by
symptoms such as weight loss/gain, and difficulty concentrating. Five or more symptoms
are generally present during this two-week period. These symptoms are represented by a
Mental Health Peace Officer
Page 11 of 97
June 2008
change from the individuals previous or “normal” functioning, morbid preoccupation
with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Symptoms of major depression may include:
 Prolonged feelings of hopelessness or excessive guilt
 Loss of interest and an inability to enjoy usual activities
 Difficulty concentrating or making decisions
 Low energy/fatigue
 Changes in activity level
 Changes in eating habits leading to weight gain or loss
 Changes in sleeping habits (sleeping more or less; an inability to fall asleep, or
waking up early in the morning and not being able to go back to sleep).
 Psychomotor agitation or retardation nearly every day
 Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, a suicide attempt or a specific plan for committing
suicide.
Instructor Note: The course of this disorder varies greatly among individuals. Some
people experience bouts of depression separated by years in which there are no reported
symptoms, some may have periods of several episodes, while others may have more and
more as they age. Research indicates the more episodes, the less time between each. Of
those who have a single episode, 50-60% will develop a second and 70% of those will
develop a third.
Statistical Facts include:
 In The U.S. approximately 14.8 million adults eighteen years or older are
diagnosed with a Major Depressive Disorder
 Median age of on-set is thirty-two
 Major Depressive Disorder is the leading Mood Disorder of persons aged 15-44
 A Major Depressive Disorder often co-exists with an anxiety or drug-related
disorder
 Single most common factor in suicidal behavior or death by suicide
Treatment for Depression:
A number of non-addictive medications are currently being used to treat depressive
disorders. Many people however, choose to self-medicate with alcohol or other nonprescribed drugs that may give them temporary relief, but due to these uncontrolled
substances lack of regulatory criteria, they tend to only increase the depressive symptoms
or create new ones.
It is recommended that persons taking medications for depression not use alcohol.
Alcohol can interact with the medications and increase alcohol’s intoxicative results,
decrease medications positive effects and/or create problems in reaction time and
judgment.
Mental Health Peace Officer
Page 12 of 97
June 2008
Instructor Note/Example:
Jim cannot believe the change in his personality. Ever since he lost his job and started
another lower paying one, he has not been the same person. He finds himself walking
around without energy to do any of the things that he used to enjoy.
Previously a hearty eater who may have been a few pounds overweight, food now has no
meaning for him and he has seen his pant size diminish two sizes. His wife has also
noticed the change. He no longer has any interest in sex, she has to goad him to pay
attention to the kids, and he never has the energy to socialize with their friends.
He spends most of his weekends sleeping now. Jim is finding it harder and harder to get
up for work and his superiors have warned him about his absentee rate. Jim often finds
himself questioning the reason for going on. He believes that if it were not for his family,
he would seriously consider ending it all.
1.4.2. Identify prominent characteristics of Bipolar Disorder:
Bipolar disorder, which has also been known as manic-depressive illness, is a brain
disorder of a severe nature, that creates unusual shifts in a person’s mood, energy level,
and ability to function. Approximately 5.7 million American adults or about 2.6 % of the
population age 18 or older in a given year are diagnosed with a bipolar disorder.
Bipolar Disorder is a mental illness involving mania (an intense enthusiasm) and
depression.
5.7 million persons with a median age of 25 suffer from Bipolar Disorder.
Symptoms of a Manic Phase may include:
 Abnormally high, expansive, or irritated mood.
 Inflated self-esteem.
 Decreased need for sleep.
 More talkative than usual.
 Flight of ideas or feeling of thoughts racing.
 Excessive risk-taking.
Instructor Note:
A manic episode is diagnosed if elevated mood occurs with three or more of the other
symptoms most of the day, nearly every day, for one or more weeks. If the mood is
irritable, four additional symptoms must be present.
Another form of mania is called hypomania and ranges from mild to moderate in its
appearance. The individual with hypomania may feel good and associate this feeling with
higher functioning and enhanced productivity and thus not willing to view the behavior
as a negative one. Hypomania however, can become severe or switch to a depressive
state.
Mental Health Peace Officer
Page 13 of 97
June 2008
Symptoms of a Depressive Phase may include:
 Prolonged feelings of sadness or hopelessness
 Feelings of guilt and worthlessness
 Difficulty concentrating or deciding
 Lack of interest
 Low energy
 Changes in activity level
 Inability to enjoy usual activities
 Fatigue
Instructor Note:
A depressive episode is diagnosed if five or more of these symptoms last most of the day,
nearly every day, for a period of 2 weeks or longer.
Instructor Note:
Also refer to section 1.4.1 Major depressive Disorder.
Severe forms of mania or depression can also include psychotic symptoms. In bipolar
disorder however, the symptoms tend to resemble the mood state the individual is in at
the time of the psychotic episode. Example: Experiencing delusions of grandiosity during
the manic phrase, such as believing individual is the President or has special powers or
wealth and delusions of guilt or worthlessness such as believing they are ruined or
penniless or has committed a horrible crime during the depressive phase. (Note:
Individuals with these symptoms are frequently misdiagnosed as having schizophrenia).
The Spectrum of Bipolar Disorder:
Severe Mania
Hypomania (mild to moderate mania)
Normal/balanced mood
Mild to moderate depression
Severe depression
In some individuals however, symptoms of mania and depression may occur together
called a mixed bipolar state. Symptoms of this state include: agitation, trouble sleeping, a
change in appetite, psychosis, and suicidal thoughts. Example: Individual is sad with a
hopeless mood simultaneously feeling extremely energized.
Mental Health Peace Officer
Page 14 of 97
June 2008
1.5. Define Anxiety Disorder
Anxiety is a normal reaction to stress. It helps a person deal with a tense situation by
helping one cope. But when anxiety becomes excessive and irrational it becomes a
disorder.
Anxiety disorders can take on many forms. You may feel a “free-floating” anxiety which
translates into not knowing what you are anxious about. You could suffer panic attacks
which are sudden, intense, and strike without warning. Your anxiety could display itself
as extreme social inhibition, a phobia, or an unwanted obsession or compulsion. These
anxieties however, have one thing in common. They are persistent and often
overwhelming and can lead to the following characteristics:
 Constant, unrelenting, and all-consuming
 Causing self-imposed isolation or emotional withdrawal
 Interference with normal activities like going outside or interacting with other
people.
Signs and symptoms of anxiety disorders could include:
 Apprehension, uneasiness, and dread
 Impaired concentration or selective attention
 Feeling restless or on edge
 Avoidance
 Hyper vigilance
 Irritability
 Confusion
 Behavioral problems
 Nervousness and jumpiness
 Self-consciousness and insecurity
 Strong desire to escape
Instructor Note:
Because of the many physical symptoms involved in anxiety disorders, many individuals
often mistake their symptoms for a physical illness.
Persons with an anxiety disorder respond to situations and events with a sense of
trepidation, fear and dread. They show physical signs of nervousness through a rapid
heart beat and profuse sweating. An anxiety disorder is diagnosed if a person cannot
control their responses and these responses are not appropriate for the situation.
Interrelated risk factors:
 Environmental Factors
o Poverty
o Early separation from the mother
o Family conflict
o Critical/strict parents
Mental Health Peace Officer
Page 15 of 97
June 2008




o Parents who are fearful/anxious themselves
o Lack of strong support system
Personality traits
o View themselves as powerless
o View the world as a threatening place
o Pessimistic leading to low self-esteem and poor coping mechanisms
Brain Chemistry
o Imbalance of neurotransmitters (serotonin, GABA, epinephrine)
o Abnormalities in the stress hormone cortisol
Heredity
o Family history of anxiety, mood or substance abuse disorders
o Biological vulnerability to stress
Trauma
o In response to traumatic event
o Early life abuse or developmental trauma
Anxiety disorders can include:
 Generalized Anxiety Disorder
 Obsessive-Compulsive Disorder
 Post traumatic Stress Disorder (PTSD)
1.5.1. Define Generalized Anxiety Disorder (GAD)
Constant worries and fears that distract from day-to-day activities and leave a persistent
feeling that something bad is about to happen. Individuals with GAD feel anxious nearly
all the time, at the same time not even knowing why these feelings have manifested
themselves. Anxiety related to GAD manifests itself through physical symptoms such as:
headaches, stomach upset, and fatigue.
Instructor Note/Example:
“I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it
would come and go, and at times it would be constant. It could go on for days. I’d worry
about what I was going to fix for a dinner party, or what would be a great present for
somebody. I just couldn’t let something go.”
“I’d have terrible sleeping problems. There were times I’d wake up wired in the middle
of the night. I had trouble concentrating, even reading the newspaper or a novel.
Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would
make me worry more. I was always imaging things were worse than they really were:
when I got a stomachache, I’d think it was an ulcer.”
Symptoms:
 Worries excessively about everyday problems for at least 6 months
 Can’t get rid of concerns even though they realize that their anxiety is greater than
the situation warrants
 Can’t relax
Mental Health Peace Officer
Page 16 of 97
June 2008




Startle easily
Difficulty concentrating
Trouble falling asleep and staying asleep
Physical symptoms: fatigue, headaches, muscle tension, muscle aches, difficulty
swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness,
having to go to the bathroom frequently, feeling out of breath, and hot flashes.
When an individual with GAD’s anxiety is mild, they can function socially and hold
down a job and only avoid certain situations as a result of the disorder. However, when it
is severe, carrying out even the simplest daily activity is impossible.
1.5.2. Describe Obsessive-Compulsive disorder
Obsessive-compulsive disorder is defined as distressing, unwanted nonsensical thoughts
which return despite efforts to ignore them and the ritualistic behavior utilized to control
these thoughts. However, the rituals used to control seem to in fact be the controller. This
disorder can affect children and adults alike.
Instructor Note:
“I couldn’t do anything without rituals. They invaded every aspect of my life. Counting
really bogged me down. I would wash my hair three times as opposed to once because
three was a good luck number and one wasn’t. It took me longer to read because I’d
count the lines in a paragraph. When I set my alarm at night, I had to set it to a number
that wouldn’t add up to a “bad number.”
“I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t
seem to overcome them until I had therapy.”
“Getting dressed in the morning was tough, because I had a routine, and if I didn’t
follow the routine, I’d get anxious and would get dressed again. I always worried that if I
didn’t do something; my parents were going to die. I’d have these terrible thoughts of
harming my parents. That was completely irrational, but the thoughts triggered more
anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable
to do a lot of things that were important to me.”
Instructor Note: Show OCD video.
Statistical data:
 2.2 million Americans have obsessive-compulsive disorder reports the National
Institute of Mental Health
 The disorder often begins during adolescence or early childhood, around age 10
 In adult onset, OCD usually occurs around age 21
 Factors which increase risk of development include: family history, stressful life
events, and pregnancy
Obsessions:
Mental Health Peace Officer
Page 17 of 97
June 2008
Obsessions are: repeated, persistent, unwanted ideas, thoughts, images or impulses that
you experience involuntarily and that appear to be senseless. These obsessive thoughts
typically intrude on your thinking and make it difficult to maintain routine life activities.
Symptoms involving obsessions can include:
 Fear of being contaminated by shaking hands or touching objects others have
touched
 Doubts that you have locked the door or turned off the stove
 Repeated thoughts that you have hurt someone in a traffic accident
 Intense distress when objects are not orderly, lined up properly, or facing the right
way
 Images of hurting your child
 Impulses to shout obscenities in inappropriate situations
 Avoidance of situations that can trigger obsessions, such as shaking hands
 Replaying pornographic images in your mind
 Dermatitis because of frequent hand washings
 Skin lesions because of picking at the skin
 Hair loss or bald spots because of hair pulling
Typically OCD obsessions revolve around:
 Fear of contamination or dirt
 Repeated doubts
 Having things orderly and symmetrical
 Aggressive or horrific images
 Sexual images
Compulsions:
Compulsions are repetitive behaviors that an individual feels driven or compelled to
perform. These behaviors are technically completed to relieve the anxiety associated with
the individual’s obsessions, but in many cases these behaviors add to the distress.
Instructor Note
Example: If you believe you ran over someone in your car, you may return to the scene
over and over because you just can’t shake your doubts. You may even make up rules or
rituals to follow that help control the anxiety you feel when having obsessive thoughts.
What type of rituals might these include?
OCD symptoms involving compulsions can include:
 Washing hands until the skin becomes raw
 Checking doors repeatedly to make sure they’re locked
 Checking the stove repeatedly to make sure its off
 Counting in certain patterns
Typically OCD compulsions revolve around:
 Washing and cleaning
Mental Health Peace Officer
Page 18 of 97
June 2008





Counting
Checking
Demanding reassurance
Repeating actions over and over
Arranging and making items appear orderly
The causes of obsessive-compulsive disorder are not fully understood but theories
include:
 Biology: Some researchers believe that OCD is a result of changes in your body
chemistry
 Environment: Some researchers believe that OCD stems from behavior habits that
you learn over time
 Insufficient serotonin: Serotonin is one of the brains chemical messengers which
when low may contribute to this disorder. Studies have illustrated this comparison
through the process of brain imaging. Individuals with OCD when medicated to
enhance serotonin levels show fewer signs of this disorder.
 Strep throat: A controversial theory is that children can develop OCD after
infection with group A beta-hemolytic streptococcal pharyngitis or strep throat.
This reportedly occurs when an antibody against strep throat bacteria mistakenly
acts like a brain enzyme, which disrupts communication between neurons in the
brain and triggers OCD.
Instructor Note:
Reminder: OCD is different than from being a perfectionist. Quality of life can decrease
dramatically as the condition dictates most of your days and you become more consumed
with carrying out compulsive behavioral rituals.
1.5.3. Discuss Post Traumatic Stress Disorder (PTSD)
Post Traumatic Stress Disorder is a type of anxiety disorder that is triggered by the
involvement in or witness to an extremely traumatic event. Unlike many individuals
involved in traumatic events these individuals’ symptoms do not improve on their own.
In fact in many cases, the symptoms can get worse lasting for months or years, disrupting
their lives and the lives of those around them.
DSMIV indicates:
The essential features of PTSD include:
“Experiencing, witnessing, or confrontation with an event or events that involve actual or
threatened death or serious injury, or a threat to the physical integrity of self or others”
“Psychic trauma is a process initiated by an event that confronts an individual with an
acute, overwhelming threat. When the event occurs, the inner agency of the mind loses its
ability to control the disorganizing effects of the experience, and disequilibrium occurs.
The trauma tears up the individuals psychological anchors, which are fixed in a secure
sense of what has been in the past and what should be in the present.”
Mental Health Peace Officer
Page 19 of 97
June 2008
Instructor Note:
“When a traumatic event occurs that represents nothing like the security of past events,
the individuals mind is unable to effectively answer basic questions of how and why it
occurred and what it means, a crisis ensues.”
“The event propels the individual into a traumatic state that lasts as long as the mind
needs to reorganize, classify, and make sense of the traumatic event. Then and only then,
does psychic equilibrium return”
“If the person can effectively integrate the trauma into conscious awareness and
organize it as part of the past (as unpleasant as that may be), then homeostasis returns,
the problem is coped with, and the individual continues to travel life’s rocky road. If the
event is not effectively integrated and is submerged from awareness, then the probability
is high that the initiating stressor will continue to assail the person and become chronic
PTSD. It may also disappear from conscious awareness and reemerge in a variety of
symptomatic forms months or years after the event. When such crisis events are caused
by the reemergence of the original unresolved stressor, they fall into the category of
delayed PTSD.” (Am. Psychiatric Assoc. 2000)
Instructor Note:
Ask students to list possible examples of causation of PTSD, such as: sexual or physical
assault, war, torture, or a natural disaster.
“I was raped when I was 25 years old. For a long time, I spoke about the rape as though
it was something that happened to someone else. I was very aware that it had happened
to me, but there was just no feeling.”
“Then I started having flashbacks. They kind of came over me like a splash of water. I
would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t
aware of anything around me; I was in a bubble, just kind of floating. And it was scary.
Having a flashback can wring you out.”
“The rape happened the week before Thanksgiving, and I can’t believe the anxiety and
fear I feel every year around the anniversary date. It’s as though I’ve seen a werewolf. I
can’t relax, sleep; don’t want to be with anyone. I wonder whether I’ll ever be free of this
terrible problem.”
PTSD is tied to the specific life event of trauma. This fact makes the diagnosis of this
mental illness much different than other mental illnesses. Post Traumatic Stress Disorder
has only been identified as a category of mental illness in the last twenty years, even
though its concept has been assigned many names over the last one hundred years. Freud
thought that traumatic childhood events had an effect on emotional development.
However it was Pierre Janet that coined the term traumatic stress, assigning a full set of
symptoms to this disorder.
Mental Health Peace Officer
Page 20 of 97
June 2008
“Shell Shock” (WWI), “Combat Fatigue” (WWII), and “Post Vietnam Syndrome”
(Vietnam War), were all identifiers assigned to this group of post traumatic stress
symptoms.
“Post-traumatic Stress Disorder is defined in terms of the trauma itself and the person’s
response to the trauma.” Trauma occurs when a person has experienced, witnessed, has
been threatened or confronted with a terrible event; response including intense fear,
helplessness, and/or horror.
An individual must meet the following conditions to be diagnosed as PTSD:
 Exposed to a traumatic event that involved an actual or threatened death or
serious injury to the physical well being of self or others. (Military combat,
physical/sexual assault, kidnapping, severe vehicle accident, life-threatening
illness, natural disaster etc.)
 Individual persistently re-experiencing the event in at least one of the following
ways:
o Recurrent and intrusive distressing recollections
o Recurrent nightmares of the event
o Flashback episodes
o Intense psychological distress or exposure to internal/external cues that
symbolize an aspect of this event
 Individual persistently avoids stimuli in at least three of the following ways:
o Attempt to avoid thoughts, dialogues, or feelings associated with trauma
o Tries to avoid activities, people, or situations that arouse recollections of
the trauma
o Inability to recall important aspects of trauma
o Markedly diminished interest in significant activities
o Feels detached and removed emotionally and socially from others
o Restricted range of affect by numbing feelings
o Sense of foreshortened future such as no career, marriage, children, or
normal life span
 Persistent symptoms of increased nervous system arousal that were not present
before the trauma, in at least 2 of the following problem areas:
o Difficulty falling or staying asleep
o Irritability or outbursts of anger
o Difficulty concentrating on tasks
o Consistently being on watch for real or imagined threats that have no basis
in reality
o Exaggerated startle reactions to nonthreatening stimuli
Susceptibility to PTSD is a function of several factors:
 Generic predisposition
 Ecological factors
 Change in brain chemistry
 Temperament
 Past life experiences
Mental Health Peace Officer
Page 21 of 97
June 2008






State of mind
Phase of maturational development at onset
Spiritual beliefs
Social support system before and after trauma
Content and intensity of the event
Increased risk factor if: Traumatic event was especially severe or intense, event
was long-lasting, have an existing mental health diagnosis, lack a good support
structure, family members also have PTSD or depression.
Symptoms of PTSD can come and go per periods of high stress or when triggered by a
symbolic (such as visual or auditory) reminder of the event. The individual then relives
the trauma creating vivid memories of the original event.
Instructor Note:
An example of a trigger could include a car backfiring that creates a flashback to combat
conditions or a news report about a rape which triggers the fear of the individuals own
rape experience.
Although trauma is the central element to the development of PTSD, other factors can
contribute to its symptoms, such as involvement in previous traumatic events especially if
they had occurred in childhood or early adolescence. In addition:
1. The characteristics and nature of the particular traumatic event,
2. The number, intensity and duration of other traumatic incidents experienced prior
to current incident,
3. Other traumatic events which are occurring in the person’s life during this same
period of time,
4. The level of social support following the incident,
5. Age: as age increases, probability of trauma decreases, and
6. Feelings of guilt, humiliation, and shame as a result of the incident
.
Anyone can have these symptoms as a result of a traumatic experience. The defining
factor is the duration of the symptoms. This duration is typically defined as three months.
As a side note, some persons do not experience symptoms of PTSD for months or years
after the incident occurrence. This is known as Delayed Onset PTSD.
Instructor Notes:
Misc. Facts:
 Distinction between natural and human-made traumas. Natural have fewer
victims of PTSD than human-made ones
 Human-made acts of trauma create even more victims of PTSD when trauma
directly affects the social support of the family
 The lines between natural and man-made traumas are narrowing. People are
beginning to look at technology as a way to control nature. EX: “God makes
rain, but the Army Corp. of Engineers made the dikes that open the floodgates.
When things go wrong, victims start looking for culprits.”
Mental Health Peace Officer
Page 22 of 97
June 2008
1.5.4. Apply knowledge gained to a discussion of at-risk occupations
Law enforcement personnel, as well as other persons in emergency service fields are a
population highly prone to suffering from PTSD, as a direct result of their work. They are
involved in traumatic events through direct or indirect involvement on a daily basis.
PTSD affects both men and women. Its effects lie not only with “front-line” personnel
but tele-communicators, dispatchers and support staff. By the basic definition of and the
diagnostic criteria for PTSD, the occupation of law enforcement is a natural “set-up” for
PTSD.
By virtue of their job, law enforcement experience or are exposed to traumatic
experiences on a recurrent basis throughout their careers. Over time, they become
accustomed to “numbing” their feelings or reactions to traumatic occurrences. They may
not even realize this is happening. Many of their daily activities may seem routine to
them when in fact they are quite stressful; seeing the events of criminal activity regularly
creates a hyper-vigilance on and off the job.
Because law enforcement officers traditionally remain in their career fields for twenty
plus years, the duration of trauma per DSMIV attributes exists and is shown through;
high divorce rates, alcoholism and suicide.
The unrealistic stereotype that law enforcement carries is also a characteristic that sets
them up for PTSD. The community mind-set is that they should be powerful and in full
control at all times, yet calm and caring; that they hold some kind of superhuman powers
that enable them to take stress and traumatic events in their stride without any detrimental
emotional results.
It is also a challenge to educate the law enforcement population to the idea of
vulnerability to this disorder and the possible need for counseling or any future utilization
of self-help strategizing. Their tendency is to avoid discussions of any topic that could
perceivably show the image of the law enforcement officer as anything other than a
controlled individual is unacceptable. They have a concern that admitting to issues of
stress, anxiety, or depressive states may affect their job status, assignments, or even
promote-ability. Consequently, law enforcement personnel are typically the last
individuals to seek help.
Biological Factors
Although psychological factors play a role in the development of PTSD, the body’s
biological response to the traumatic experiences is responsible for the symptom
development. Exposure to a traumatic incident activates numerous brain and body
systems. It increases hormonal levels, to include: adrenaline, norepinephrine, thyroid, and
testosterone, to prepare the body for “fight or flight.” This increase affects heart rate,
blood pressure and as well as changes in muscles, senses, and other body structures. In
most situations these physical changes are short-lived, but in individuals who develop
PTSD these high levels continue as if they are still experiencing the traumatic event.
Mental Health Peace Officer
Page 23 of 97
June 2008
These physical changes then lead to other problems such as sleeping and concentration.
Probably however, the most disturbing is the memory of the traumatic event frozen in the
memory of the individual; there it is often re-experienced over and over keeping the
incident in the present.
Examples of the negative impact of PTSD on body systems:
1. Issues of the Cardiovascular System
2. Compromised immune system
3. Chronic pain, back problems, headaches, gastrointestinal problems
Instructor Notes:
Misc. facts for review:
 Neurotransmitters of the brain and nervous system play a role in PTSD. Even if
the person is removed from the trauma, the nervous system may continue to
function in this elevated/energized state as if the trauma is continuing.
 Continued stress can cause permanent physical changes to occur in the brain.
This long term effect explains why people just don’t “get over” PTSD.
 Stimuli of sights, sounds, and smells associated with long-past event can send the
neuroendocrine system into overdrive and cause a physiological response.
Bottom Line;
“In doing their jobs, these individuals can develop debilitating symptoms after working
traumatic job-related incidents. These symptoms can lead to poorer job performance, an
increased potential to be injured or killed on-the-job, increased potential for problems
with alcohol, as well as problems which impact on their personal life.”
Instructor Note/Discussion:
Suicide and substance abuse may be the end products of attempting to cope with trauma.
1.6. Discuss the term Cognitive Disorder
Cognition refers to that operation of the mind process by which we become aware of
objects of thought and perception, including all aspects of perceiving, thinking, and
remembering.
Symptoms related to Cognitive disorders (drug related disorders included):
 A major loss of contact with reality
 A gross interference with the ability to meet life’s demands
 Possible delusions and hallucinations
 Alteration of mood
 Defects in perception, language, memory and cognition
The two most common cognitive disorders include:
 Alzheimer’s Disease
 Substance Abuse Disorders
Mental Health Peace Officer
Page 24 of 97
June 2008
1.6.1. Discuss the most commonly addressed organic brain disorder
The most common Organic Brain Disorder in persons over the age of 65 is Alzheimer’s
disease. Alzheimer’s is one of several disorders that cause a gradual loss of brain cells.
The disease was first identified in 1906 by Dr. Alois Alzheimer and was considered rare
at that time. Research is now showing it to be the leading cause of dementia.
The cause of all demensia is abnormal loss of brain tissue. Demensia is characterized by
loss of memory PLUS one or more of the following:
 Aphasia-loss of language
 Apraxia-loss of knowledge of how to do things (tie shoes etc.)
 Agnosia-loss of ability to recognize things and what you do with them
 Loss of higher executive functioning-ability to plan and organize (one of the first
things to go)
An individual experiencing this disease may get lost easily, have poor memory, and
become easily agitated. It is estimated that 4 to 5 million Americans are afflicted with
Alzheimer’s and over 11,000 die each year from this disease. This estimate has more than
doubled since 1980.
Identifying Persons with Alzheimer’s
In general, persons with Alzheimer’s may exhibit some or all of the following symptoms
by stages:
 Very mild to severe Cognitive decline.
 Feelings of memory lapse, to include forgetting simple words, names and location
of such things as keys or valuable objects.
 Decreased knowledge of recent occasions and events as well as day-to-day task
completion, such as bill paying, grocery and basic arithmetic.
 In need of assistance with basic personal issues such as choosing clothes by
occasion or season, dressing themselves (shoes on wrong feet) and hygiene needs.
 Loss of awareness of surroundings to include wandering and disorientation.
 Loss of the ability to respond to environment thru speech and control of
movement, steady decline from walking to sitting to holding head up. Reflexes
become abnormal and muscles rigid.
Symptoms of Alzheimer’s differ between persons. Not everyone will experience all of
the symptoms or may they occur at different times with varied severities. Global
Deterioration however, seems consistent with the disease.
Communicating With Persons With Alzheimer’s
Due to reduced short-term memory, victims may ask you questions, such as who you are,
repeatedly. Be ready to reintroduce yourself multiple times and approach persons from
the front with good eye contact. Introduce yourself, as law enforcement and that you are
there to help. Be patient with slow responses and repeated questions.
Mental Health Peace Officer
Page 25 of 97
June 2008









Ask for identification and notice if the person has a “Safe-return” bracelet or
necklace stating medical difficulties.
Treat with dignity. They continue to have feelings even if brain deterioration has
begun.
Guide person to a quiet location away from crowds and on-lookers. Noisy
environments can tend to confuse and agitate. Be aware of any signs of
frustration, such as pacing, restlessness or panic, which may further distress the
victim. Lessen additional stimuli by turning off car’s flashing lights and lowering
car radio.
Speak in a low-toned reassuring voice while maintaining eye contact.
Utilize short simple sentences, spoken clearly
Understand people with Alzheimer’s have short attention spans and can be easily
agitated. Repeat yourself often and utilize gestures for clarification without
sudden movement.
Explain your actions before beginning any processes.
Do not argue or challenge person. Be prepared for answers to questions to be
confusing and answered differently if asked twice.
Do not leave person alone and find emergency shelter by contacting the
Alzheimer’s Association if residence or caregiver cannot be located.
Gerwo, Josh R. Psychology: An Introduction. (3rd ed.) Harper-Collins Publishers
National Institute of Mental health, 2006
Instructor Notes:
Additional Facts:
 NOT considered a mental illness and most mental health facilities will not admit
Alzheimer’s patients
 Drugs can help the progression of the disease but there is no cure.
 It is now being diagnosed in persons considerably younger than 65. An inherited
form of Alzheimer’s disease can affect younger persons, ages 30 to 40 but
remains rare in its diagnosis.
1.6.2. Discuss the relevance of addressing substance abuse disorders in the topic of
mental illness
Prolonged abuse of any drug (alcohol, prescription medications or “street drugs”) can
cause chemical dependency or addiction. If these substances are used for extended
periods of time and/or in large dosages, they may also cause permanent damage to the
central nervous system. This damage can cause a wide range of psychological reactions
that are classified as disorders. Examples of such psychological reactions are:
 Smoking a stimulant like crack cocaine can cause paranoid symptoms
 Prolonged alcohol use can produce depressive symptoms
 A person who is physically dependent on Heroin will exhibit anxiety if usage is
discontinued
Mental Health Peace Officer
Page 26 of 97
June 2008
Further examples of the association between Substance Abuse and Mental Illness, as well
as symptoms of their usage include:
Cannabis Intoxication
 Impaired muscle coordination, euphoria, anxiety, sensation of slowed time,
impaired judgment
 Red eyes, sleepy look
 Dry mouth
 Increase in heart rate
Instructor Note:
Hydroponically created (genetically engineered) Cannabis can make an overdose much
more prevalent. THC levels have dramatically increased in this new derivative from 5%
to 20-25%. Symptoms of an overdose can resemble an asthma or severe panic attack.
Cocaine Intoxication
 Changes in sociability, euphoria, interpersonal sensitivity, anxiety, hypervigilance, impaired judgment
 Abnormal heart rate, dilated pupils, abnormal blood pressure, perspiration or
chills, seizures
 Psychomotor agitation
 Difficulty performing voluntary movements
Hallucinogenic Intoxication
 Marked anxiety or depression, paranoid ideation, impaired judgment, fear of
“losing one’s mind”
 Intensified perceptions, illusions, hallucinations while awake and alert
 Dilated pupils, increased heart rate, blurred vision, sweating, loss of muscle
coordination and tremors
Sedative, Hypnotic, or Anxiolytic Intoxication
 Inappropriate sexual or aggressive behavior, mood swings
 Slurred speech, loss of muscle coordination, unsteady gait, rhythmic oscillation of
eyeballs
Illegal drug and alcohol usage is also a primary concern for individuals with a preexisting mental illness. These substances can have an adverse effect when used in
combination with prescribed medications and can create a masking effect of more severe
symptoms associated with a mental illness.
Use of illegal drugs and alcohol can be used in a self-medicating way. An individual may
use illegal substances or alcohol to help them feel more “normal.” But instead, this style
of usage could create a dependency or a roller coaster effect due to lack of consistency
and medical monitoring of the chosen illegal substances. An individual with a mental
Mental Health Peace Officer
Page 27 of 97
June 2008
illness and a dependency to alcohol and/or drugs is referred to as having a co-occurring
disorder (formerly termed dual-diagnosis.)
Co-occurring Disorders refers to the co-occurrence of mental health disorders and
substance abuse disorders, which would include alcohol and/or drug dependence or
abuse. There is no one type of Co-occurring Disorders, disposing persons to an array of
disorder combinations. As a result of these differences, a variety of problems are also
possible. For example: Substance Abuse or dependency left untreated can contribute to a
return of psychiatric symptoms and conversely psychiatric disorders left untreated can
trigger a relapse with alcohol or drugs. Alcohol or drug use has also been known to mask
psychiatric issues as well as the withdrawal from used substances can mimic symptoms
of a mental illness.
A Co-occurring Disorder profile may be represented by the following:



Severe mental illness and a substance disorder.
Substance disorder and a personality disorder
Personality disorder, substance abuse disorder with symptoms requiring
psychiatric care, like hallucinations or depression.
Occurrences of other problems could lead to law enforcement involvement. Examples
could be: Financial problems leading to homelessness, health emergencies, and disorderly
conduct due to relapse or return of psychiatric symptoms, family violence, and erratic
driving behavior.
Crisis in a substance abusers life is constant. “They use drugs to shield themselves from
all sorts of hurtful feelings, thoughts, and behaviors. Once the shield is taken away, all
problems tend to converge. The reasons they used in the first place return, condensed,
magnified and in more powerful ways. Each incident creates a crisis.”
“It is not the event itself but our belief about that event that causes us to feel and act in
certain irrational ways. By starting to think, ‘insane’ thoughts about what people or
events should/ought/must do or be to make a perfect world they become victims of their
own irrational thoughts about the events.”
Which Develops First – Substance Abuse or the Co-occurring Disorder?
Of all persons diagnosed with a mental illness, twenty-nine percent abuse either alcohol
or drugs. Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers
have at least one serious mental illness.
Often the psychiatric problem appears first leading to self-medication. Self-medication
occurs as a desire to feel “normal”, calm, have more energy, or feel happier. The usage of
alcohol or drugs can fulfill this void. Self-medication can occur for a variety of reasons.
Most common of these is a misguided attempt to medicate without knowledge of the
underlying condition. Secondly, until recently medications to treat psychiatric disorders
produced uncomfortable side effects, which could be temporarily alleviated by using
Mental Health Peace Officer
Page 28 of 97
June 2008
illegal substances. Thirdly are social factors. Some persons may feel they would be more
accepted being noted as a drug abuser than mentally ill. Utilizing this technique may lead
to alcohol or drug dependency, creating two problems instead of the one. Conversely
extensive alcohol/drug usage as an adolescent carried over to adulthood can lead to
psychological or developmental disorders.
If in fact a person is suspected of both a mental illness and a substance abuse problem,
where should they be referred? Ideally both disorders should be treated simultaneously.
However, a lot of facilities for one disorder do not treat the other. It is important that
community resources be investigated in advance so that you are aware of your options for
this situational referral.
Identifying Persons with a Co-occurring Disorders Disorder:
Identifying mentally ill persons who also have a Substance Abuse problem is extremely
difficult. Sometimes a person will begin the withdrawal process before the underlying
issues of the co-occurring disorder will show itself.
Behaviors such as slurred speech, unsteady gait, disorientation and argumentativeness
can be associated with the substance abuse or the mental illness, so observation of these
behaviors are not always a reliable way to differentiate between the two disorders. Usage
of our observation techniques may be more successful such as, possession of drug
paraphernalia, needle marks, strong aroma or odor, medical alert jewelry or ID,
prescription medications on the person.
Communicating with Persons with a Co-occurring:
Communication can tend to be difficult. If confrontation is to be utilized, it is best to wait
until the person is not under the influence of drugs or alcohol. Avoid making threats of
jail or hospital it will only agitate the individual, which could result in violent behavior.
Violence is more prevalent among this group to include domestic violence and suicide.
Upon confronting the individual, concentrate on the behavior at hand; requesting specific
behavior to correct the current problem behavior. Avoid a moralistic tone of voice or
drawing conclusions about the individual. Again concentrate on the behavior and the
consequences of the behavior and be solution oriented to assist the individual in regaining
personal control.
Instructor Notes:
Exercise, Role-play activity:
Description of the scene:
You have been called to a family residence where you have prior knowledge that a 31year old mentally ill male resides with his elderly parents. Arriving at the residence you
find the mother standing in the front yard, holding her already bruising face and
motioning for us to hurry inside. Upon entry you note a highly agitated male pacing back
and forth blocking an elderly males exit from the house. As you slowly approach the son
you note he is speaking in nonsensical sentences seemly to an unknown source is
perspiring profusely and has an odd odor about his person How will you need to
Mental Health Peace Officer
Page 29 of 97
June 2008
communicate with the son to obtain assistance for all family members involved in the
confrontation?
1.7. Define the term Personality Disorder
American Psychiatric Association (APA) defines as "an enduring pattern of inner
experience and behavior that deviates markedly from the expectations of the culture of
the individual who exhibits it".
A deeply ingrained, inflexible, maladaptive pattern of relating, perceiving and thinking
serious enough to cause distress or impaired functioning. ... a class of mental disorders
characterized by rigid and on-going patterns of thought and action.
1.7.1. Discuss examples of Paranoid Personality Disorder
Paranoid Personality Disorder is an on-going unfounded distrust and suspiciousness of
people. Paranoia can be mild and the person can function fairly normal in society or it
can be so severe that the suspiciousness and perceived malevolent behavior disrupts work
and family life.
“Paranoid personality disorder is a psychiatric diagnosis characterized by paranoia
characterized by a pervasive and long-standing suspiciousness and generalized mistrust
of others.” (DSM-IV)
It is difficult to determine the number of people with PPD with any accuracy due to
insufficient data. This lack of data might be expected for a disorder that is characterized
by extreme suspiciousness.
According to the DSM-IV:
 Between 0.5% and 2.5% of the general population of the United States may have
PPD
 2%–10% of outpatients receiving psychiatric care may be affected
 A significant percentage of institutionalized psychiatric patients, between 10%
and 30%, might have symptoms that qualify for a diagnosis of PPD
 More common in men than in women.
Individuals diagnosed with PPD will possess at least four of the following symptoms:
 Unfounded suspicion that people want to deceive, exploit or harm
 Belief that others are not trustworthy
 Fear that others will use information against them with the intention of harm
 Interpretation of others' innocent remarks as insulting or demeaning
 Interpretation of neutral events as presenting or conveying a threat.
 Strong tendency not to forgive real or imagined slights and insults
 Angry and aggressive response in reply to imagined attacks by others
 Suspicions, in the absence of any real evidence, that a spouse or sexual partner is
not sexually faithful, resulting in such repeated questions as "Where have you
been?" "Whom did you see?" etc. and other types of jealous behavior.
Mental Health Peace Officer
Page 30 of 97
June 2008
Identifying Persons with a Paranoid Personality Disorder:
Symptoms begin in early adulthood and can be seen and acted on in a variety of ways as
follows:
 Suspicious: Persons with a paranoid personality are continually on guard because
they view the world as a threatening place. Placed in a new situation we are
naturally cautious until we learn our fears are unsupported however, persons with
Paranoid Personality Disorder cannot abandon these fears. They suspect without
any basis, that others are harming or deceiving them.

Hypersensitive: Persons with this disorder tend to be in a state of hyper alert
continually. They notice the smallest behavior toward them and turn it around and
take offense when none was intended. They are highly critical of others but
cannot accept criticism themselves.

Problems with Intimacy: Persons with Paranoid Personality Disorder tend to have
difficulty maintaining close or intimate relationships due to their lack of trust in
other people. They tend to be preoccupied with perceived doubts about loyalty
and trustworthiness, suspecting that confidential information will be used
maliciously against them. This thinking also extends to their significant other who
they believe is cheating on them and the filing of unsubstantiated law suits in an
attempt to keep people from taking advantage of them.

Hold Grudges: Persons with Paranoid Personality Disorder regularly turn
innocent comments around to perceive them as demeaning or threatening. They
then become unforgiving of these perceived insults or slights. They are known for
blaming other people for their problems and to immediately react in a
counterattack of argumentativeness, defensiveness, deceptions, and unwillingness
to compromise.
Individuals with this disorder exhibit a strong need for self-sufficiency; are rigid and are
often argumentative. Because they avoid closeness with others, they may seem cold and
calculating. Usually men are diagnosed with Paranoid personality Disorder more than
women.
Causes:
 Specific cause of this disorder is unknown, but there is increased incidence of the
disorder in families with a history of schizophrenia.
 Can result from negative childhood experiences
 As a result of a threatening home environment
 Often prompted by extreme and unfounded parental rage resulting in childhood
insecurities
 Often prompted by a condescending parental influence resulting in childhood
insecurities
Communication with Persons with a Paranoid Personality Disorder
Mental Health Peace Officer
Page 31 of 97
June 2008




Paranoid individuals become suspicious without cause. Approach in a calm
manner not to increase this distress. Any person is a potential adversary.
Open-ended questions make them suspicious.
Keep body movements to a minimum due to person’s hypersensitive nature.
Power struggles are easily entered into with this disorder due to their inert
stubbornness as well as defensive stance.
Remain in today, do not agree or disagree with a delusional thought or
behavior.
Instructor Note/Role-play:
Description of scene:
As the Mental Health Officer on duty, you are called to a residence by the parents of a
22-year-old male previously diagnosed with Paranoid Personality Disorder. Upon
arrival, the parents escort you to the hallway outside their son’s room. There is a foul
odor emitting itself from the room and it is explained to you that the son has not come out
of his room for five days. The son is currently calling for help and accusing the parents in
trying to take him to hospital to have experimental research done on him. It is also
relayed to you that he has not been eating because he feels that is part of the plan to
sedate him and take him to the hospital for the experiments. He has not come out of the
room to wash or use the facilities due to an apparent suction in the drain, which could
transport him to the hospital morgue. Utilizing the information you have gotten from this
unit, what would your actions include?
1.7.2. Discuss relevant characteristics of Antisocial Personality Disorder
Antisocial Personality Disorder is a psychiatric condition. It can be expressed through
behavior that is manipulative. It often victimizes and violates the rights of others. Persons
with this disorder, fail to conform to societal norms and often have a history of juvenile
conduct disorder and criminal activities prompted by reckless, impulsive and violent
behaviors. This disorder is also most common in men.
Causes and characteristics of an Antisocial Personality Disorder:
The cause is relatively unknown. However, there are common traits that are associated in
persons with this disorder which may include: chronic boredom, irritability,
alcohol/substance abuse and a variety of anxiety disorders.
Other common factors associated with this disorder could include:
Family dynamics
 Family violence
 Excessive or absence of discipline
 Substance abuse history in family
 Neglect or abandonment
 Physical and/or sexual abuse
Biological and neurological
 Frontal lobe (controls judgment and planning) abnormalities
Mental Health Peace Officer
Page 32 of 97
June 2008



Diminished startle reflex
Serotonin dysfunction
Hyperactivity
Cognitive (thinking errors)
 Ownership attitude
 Uniqueness
 Power thrust
 Victim stance
 Closed channel thinking
Identifying Persons with Antisocial Personality Disorder:
 Juvenile Conduct Disorder: prior record may be present.
 Socially unacceptable behavior noted: deceitful, impulsive, aggressive or irritable,
reckless, irresponsible or unremorseful behaviors
 Noted when approaching: challenging of authority figure, chronic lying,
rationalizing criminal acts, lack of remorse, and excusing oneself from moral
obligations
 Rape and sexual sadism are also common
Instructor Note:
Communication with a person with Antisocial Personality Disorder can be a challenge.
In fact, they will challenge you and your authority over and over again. Their behavior is
manipulative. It is advisable to not get into power struggles with the individual. Acting
self-assured, relaxed but direct in your questioning, and setting clear boundaries should
assist you in your communicative approach.
1.8. List the most common mental disorders that are first diagnosed prior to the age
of eighteen
Three of the most common disorders that are first diagnosed prior to the age of eighteen
are the developmental disorders of Autism Spectrum Disorder (ASD), Mental
Retardation, and Attention Deficit Hyperactivity Disorder (ADHD).
The Developmental Disabilities Assistance and Bill of Rights Act of 1990 defines a
developmental disability as a severe, chronic disability of a person five years of age or
older. Such a disability
 Is attributable to a mental or physical impairment or combination of the two
 Is manifested before a person reached the age of twenty-two
 May continue indefinitely
 Substantial limitation of three or more specified life activities (self-care,
language, learning, mobility, self-direction, independent living, and economic
self-sufficiency); and
Mental Health Peace Officer
Page 33 of 97
June 2008

Reflects the person’s need for lifelong or extended care, treatment, or other
services which are planned and coordinated according to that person’s needs.
Infants and young children (newborn to age 5) with developmental disabilities
have substantially delayed development or specific congenital or acquired
conditions
Instructor Note:
Put more simply, a DD is a condition that an individual may have had since birth or
childhood which has prevented them from full social or vocational independence in
adulthood, and which continues on into old age. The four kinds of life skills that are
normally mastered and could be affected during this time are: Gross motor, fine motor,
communication and social skills.
A developmental disorder is characterized by:
 Impaired non-verbal communication, including abnormal speech patterns or loss
of speech
 Lack of eye contact
 Restricted range of interest
 Resistance to change of any kind
 Obsessive repetitive body movements
 Lack of awareness of the existence or feelings of others
 Social isolation.
1.8.1. Discuss Autism Spectrum Disorder (ASD)
Autism is a brain developmental disorder that impairs social interaction and
communication; causing restricted and repetitive behavior, all starting before the age of
three. Symptoms vary from child to child and can range from mild to severe. The most
severe form being called Autistic Disorder to the milder form called Asperger Syndrome.
If the child does not meet the criteria for either, the diagnosis is referred to as pervasive
developmental disorder not otherwise specified (PDD-NOS). Other rare, but very severe
disorders that are included in this category are Rett syndrome and Childhood
Disintegrative Disorder.
Statistics concerning prevalence of Autism may differ due to changes in diagnostic
criteria. However, most agreed upon information states:
 3-4 cases of Autism in every 1000 children
 Diagnosis is four times higher in boys than girls
 Usually appears by the age of three
 When Autism appears in girls it tends to be more severe
Instructor Note:
Reference: The Concise Columbia Encyclopedia is licensed from Columbia University
Press. Copyright 1995 by Columbia University Press.
Mental Health Peace Officer
Page 34 of 97
June 2008
Parents are usually the first to notice unusual behavior in their child. In some cases the
baby seemed “different” from birth, unresponsive to people or focusing intently on one
item for long periods of time. The first signs can also appear in children who seemed to
be developing normally. When an engaging, babbling toddler suddenly becomes silent,
withdrawn, self-abusive, or indifferent to social overtures, something is wrong.
Children with ASD do not follow the typical patterns of child development. In some
children, hints of future problems may be apparent from birth. In most cases, the
problems with communication and social skills become more noticeable as the child lags
further behind other children the same age. “The child may act as if unaware of the
coming and going of others, or physically attack and injure others without provocation”
(NIMH, Unraveling Autism, 2001).
ASD is defined by a specific set of behaviors that can range from very mild to severe.
 Does not babble, point, or make meaningful gestures by 1 year of age
 Does not speak one word by 16 months
 Does not combine two words by 2 years
 Does not respond to name
 Loses language or social skills
Persons with Autism are also more prevalent to sensory disorders that keep them from
effectively filtering and blocking painful sensations. These sensory disorders can cause
extreme pain from loud noises and bright light. This pain can develop into frustration and
acts of aggression.
Officers in contact with these individuals will notice certain behaviors such as:
Common Social Behaviors:
 Lack of awareness of social rules
 Reluctance to make eye contact
 Inappropriate laughter or crying
 Unusual facial responses
 Ritualistic, habitual behaviors
 Extreme distress for no apparent reason
 Attachment to particular objects
 Deliberate soiling of clothes
 Uneven motor skills
 Self stimulating Behaviors
Common Communication Behaviors:
 May be verbally limited
 May repeat what is said
 Abnormal pitch, rate or volume when speaking
 Difficulty expressing ideas or needs
 Reversal of pronouns or other parts of speech
Mental Health Peace Officer
Page 35 of 97
June 2008

Difficulty with abstract concepts and terms
Other Behavioral Cues:
 Matching, pairing and ordering objects
 Blinking compulsively
 Switching lights on and off
 Dropping things repetitively
 Jumping, Rocking and Clapping
 Chin-tapping, Head-banging, Spinning
 Fascination with colorful and shiny objects
1.8.2. Define Mental Retardation
Mental Retardation (MR) refers to a range of substantial limitations in mental functioning
manifested in persons before the age of 18, creating a pattern of slow learning during
childhood and significantly below normal global intellectual functioning as an adult. This
below-level intellectual functioning combined with a limitation in two or more of the
following adaptive skill areas is utilized in diagnosis.
 Communication
 Self-care
 Home living
 Social skills
 Health
 Safety
 Academic functioning
 Work
The following categories are connotative to the degree of the Mental Retardation:
 Borderline: 70-79
 Mild: IQ 50-69
 Moderate: IQ 35-49
 Severe: IQ 20-34
 Profound: Below 20
Instructor Note:
Mild: May not be obvious or diagnosed until school age. Expert assessment will be
needed to differentiate between mental retardation and a learning disability. Adults in
this category usually live independently but are considered by the community as “slow”
instead of mentally retarded.
Moderate: Usually obvious prior to the age of 5. Will encounter difficulties in school,
where they will need special classes to progress and to become functional. As adults they
will live with parents, in a group home, or if significant support services are available
may live semi-independently.
Mental Health Peace Officer
Page 36 of 97
June 2008
Severe: This category will involve intensive support and supervision their entire life span.
Testing results via Wechler Intellegence Scale or Standford Binet IQ test.
Persons with mental retardation may be described as having a developmental disability,
global developmental delay, and/or learning difficulties. Children may learn to sit up,
crawl or walk later than other children and both children and adults may have trouble in
the following areas:
 Speaking
 Remembering
 Discerning cause and effect
 Solving problems
 Thinking logically
 Persistence of infantile behavior
Instructor Note:
Performance Tasks can be utilized by officers upon contact, to help determine if problem
exists:
 Read/write simple phrases
 Identify telephone number in book
 Give directions to their home
 Tell time
 Count to 100 by multiples of five
 Define abstract terms (such as emotions or feeling terms)
 Explain how to make change from a dollar
Note: When performance tasks are used, be cognoscente of the consumers dignity. The
officer needs to realize that failing a performance task could cause humiliation when
conducted, especially in public. This humiliation could then turn quickly to aggression.
The most common causes of mental retardation are Downs Syndrome, Fetal Alcohol
Syndrome and Fragile X Syndrome. Many other factors however have been identified as
possible causes:
 Genetic conditions
 Problems during pregnancy or at birth
 Health issues
 Iodine deficiency-leading preventable cause
 Malnutrition
 Use of forceps
 Institutionalization at young age
 Sensory deprivation-severe environmental restrictions, prolonged isolation or
severe atypical parent-child interactions.
Mental Health Peace Officer
Page 37 of 97
June 2008
1.8.3. Explain the primary differences that exist between a Mental Illness and
Mental Retardation
Instructor Note/Discussion:
What are the significant differences between Mental Illness and Mental Retardation?
Mental Illness vs. Mental Retardation Statistics:
 3% of the American population is considered to posses a mental retardedation
(sub-average score of 69 or less on Wechler Intelligence Scale or Stanford Binet
IQ test).
 While…22.1% of the American population is diagnosed with a mental illness.
Instructor Note:
Reference: Special Olympics (http://www.specialolympicspa.org)
Differences between mental illness and mental retardation include:
Mental Illness
Unrelated to intelligence
Develops at any point in life
No cure but medications can help
Behavior less predictable
Mental Retardation
Below average intellectual functioning
Occurs prior to the age of 18
Permanent intellectual impairment
Behavior consistent to functional level
1.8.4. Describe prevalent factors of Attention Deficit Hyperactivity Disorder
(ADHD)
Attention-deficit hyperactivity disorder (ADHD) is a medical condition characterized by
difficulties with inattention or hyperactivity and impulsivity. Symptoms must be severe
enough to disrupt daily functioning in two or more settings (EX: school, home, work).
Children with ADHD are in constant motion, dashing around touching everything in
sight, jumping on and off the furniture. They often:
 Blurt out inappropriate comments
 Don’t wait their turn
 Show excessively intense emotions
 Hit others when upset
Hyperactive and impulsive adults feel restless
 Constantly “on the go”
 Try to do multiple tasks at once
 Perceived as not thinking before they act or speak
“In adults, it’s a much more elaborate disorder than in children,” says Russell Barkley,
Ph.D., a Psychiatry professor at the Medial University of South Carolina. “It’s more than
paying attention and controlling impulses. The problem is developing self-regulation.”
Mental Health Peace Officer
Page 38 of 97
June 2008
“This self-control affects an adult’s ability not just to do tasks, but to determine when
they need to be done,” says Berkley. “You don’t expect 4 or 5 year olds to have a sense
of time and organization, but adults need goal-directed behavior, they need help in
planning for the future and remembering things that have to get done.”
There are three types of attention deficit hyperactivity disorders (ADHD) as defined by
the Diagnostic and Statistical Manual of Mental Disorders (DSM IV):
1. Hyperactive/Impulsive type: 80% of boys have this type and 80% of girls do not.
As matures, hyperactivity tends to internalize and become feelings of restlessness,
fidgeting, or constant movement. Impulsivity also is internalized with a constant
inner battle to keep comments to ones self.
2. Inattentive type: 20% of boys, but 80% in girls. As matures, inattention increases
as individuals juggle more responsibilities and life gets more complicated
3. Combined type: Combination of above symptoms.
Statistical Information (Prevalence):
 5% of children in United States have ADHD
 Boys more frequently than girls (3:1)
ADHD is frequently co-morbid or occurring with a behavior disorder. An example of this
co-morbidity could include ADHD with:
 Oppositional Defiant Disorder (ODD)
 Conduct disorder
 Substance abuse
 Impulse Control Disorders
Symptoms in a possible diagnosis of ADHD::
1. Six or more of the following symptoms of inattention have been present for at least six
months and are inappropriate and disruptive for the individual’s developmental level:
 Lack of close attention to details, or makes careless mistakes
 Has difficulty keeping on task
 Seemingly inattentive when spoken to
 Does not follow directions or complete tasks due to oppositional behavior or
failure to understand instructions
 Trouble organizing activities
 Avoids or dislikes completing tasks that take much mental effort for a lengthy
time
 Losses things needed to complete tasks or activities
 Easily distractible
 Often forgetful in daily activities
2. Six or more of the following symptoms of hyperactivity-impulsivity have been
present for six months to an extent that is disruptive and inappropriate for
developmental level:
Hyperactivity
Mental Health Peace Officer
Page 39 of 97
June 2008






Fidgets with hands or feet or squirms in seat
Gets out of seat when expected to remain seated
Runs about or climbs when and where inappropriate (children), Feelings of
restlessness (adults)
Has trouble enjoying leisure activities quietly
“On the go” or acts like they are being “Driven by a motor”
Talks excessively
Impulsivity
 Blurts out answers before questioning has been completed
 Trouble waiting turn
 Interrupts or intrudes on others
Instructor Note:
Paradox: Medicating an individual with ADHD with a stimulant “slows down”
hyperactivity by stimulation of an inhibitory dopamine system and the stimulation of the
frontal cortex which helps with executive functions such as concentration and
organization. Treatment with stimulants has been shown to reduce the propensity of
substance abuse due to the control of impulsivity and lack of need to experiment with
self-medicaton.
Mental Health Peace Officer
Page 40 of 97
June 2008
2.0. Discuss psychopharmacology as it relates to medications prescribed and
prominent side effects in persons with a mental illness.
The widespread use of drugs for treatment among persons with a mental illness is a
relatively new development. Treatment with medications began during the 1950’s, and
continues to be an effective option for individuals with a mental illness. While it is not a
cure, they are used to control symptoms and improve coping skills, which can then help
reduce the severity of the mental illness. Most individuals who are on psychotherapeutic
medications for mental illness will continue taking them for the rest of their lives.
2.1. Name four categories of medications utilized in controlling the symptoms of
mental Illness.
Categories of drugs:
 Anti-psychotic
o Used for persons with schizophrenia
o Improves the effects of delusions and hallucinations
o Thorazine was first widely utilized
o How it functions: blocks dopamine receptors at the synapse which in turn
reduces brain activity.
o Possible side effects: dulling of physical and mental functioning, tardive
dyskenesia and sedation
 Antidepressants
o Used for persons with major depression or bipolar disorder
o Includes monoamine oxidase inhibitors (MAO) and tricyclics
o How MAO’s work: increases the hormones or neurotransmitters in the
sympathetic nervous system
o Today’s tricyclic compounds: amitriptyline (Elavil), serotonin increasers
(Prozac), seraline HCL (Zoloft). Chemically similiar to previous
medications for depression however, tricyclic compounds activate rather
than tranquilize.
 Mood stabilizers (Hallucinogenic)
o Particularly used to control manic episodes (element lithium is an antimanic)
o How it works: Lithium alters the transport of sodium ions in nerve and
muscle cells and affects the metabolism of catecholamines.
 Anti-anxiety drugs
o Includes: meprobarnate (Equanil) and benzodiazehines
(Diazepam/Valium)
o How it works: Reduces tension and anxiety but can lead to addiction. In
small doses they relieve anxiety by reducing muscular tension and in
larger doses produce sedation, sleep and anesthesia.
o Chemically diverse group with similar psychological effects
Mental Health Peace Officer
Page 41 of 97
June 2008
Just as aspirin can reduce a fever without curing the infection that causes it, psychotherapeutic medications act by controlling symptoms but do not cure the mental illness.
They do however; allow the person more ability to function.
Instructor Note/Examples:
 Chlorpomazine can turn off the “voices” and help to see reality clearer but it
does not cure Schizophrenia.
 Antidepressants can improve moods but does not cure major depression.
Medications react differently on every individual. Some respond better to one medication
than another. Some individuals have side effects and some do not.
2.2. List side effects that can be associated with utilizing psychotherapeutic
medications:
There is an “old” class of drugs, such as Haldol, that have some very negative side
effects, that includes severe sedation, possible impotence, etc. There is also a “new” class
of drugs that treat the disease with fewer side effects. The “older” drugs are still in use
today. It is important to be familiar with the older medications, due to their more
prevalent usage with the indigent and jail populations. The newer antipsychotic
medications are more costly.
Instructor Note:
Old vs. new drugs - new drugs have significantly fewer side effects, but old drugs are still
used today, especially with the indigent (due to lower costs)
Examples of side effects could include: muscle spasms, protruding tongue, eyes rolled
back, constant leg movement, tremors, uncoordinated movements, impotence, nausea,
headache, blurred vision, weight gain, fatigue, liver toxicity
Side effects can be
 uncomfortable
 dehumanizing
 and are often irreversible, which may cause person to refuse to take them as
directed
Some of these side effects are permanent, even after the medications have been stopped;
the medications have a tendency to produce neurological damage. This neurological
damage is termed Tartive Dyskenesia.
Instructor Note:
Many of these medications are also lethal when taken in excess. Careful monitoring is
necessary due to many consumer symptoms already include disorganization and difficulty
remembering.
Mental Health Peace Officer
Page 42 of 97
June 2008
2.3. Define Tardive Dyskinsia (TD) and its relationship to the utilization of
psychotherapeutic medications
Tardive Dyskinesia refers to a neuromuscular disorder caused by the long-term use of
certain tranquilizers (neuroleptic drugs). These drugs are usually prescribed for
psychiatric disorders as well as some neurological and gastrointestinal disorders. These
prescribed medications block the receptors for the neurotransmitter dopamine in the
brain, which is the receptor involved in producing movement. If the receptors are
blocked, over time, some persons may develop uncontrolled involuntary muscle
responses or movement.
Classic involuntary movements may include tongue thrusting, lip smacking, lip pursing,
rapid eye blinking, chewing movements, rocking of the trunk, rotation of the ankles or
legs, marching in place, impaired finger movements, irregular respirations and sounds
like humming or grunting. As you can see, these movements tend to be repetitive and
somewhat rhythmical in nature.
Onset of these symptoms can occur within a few months after initiating this medication
or may wait up to several years before initiation. There is also the possibility of having an
“acute reaction” that may occur within hours of ingesting medication. Acute reactions are
more easily managed and usually completely resolve within a few days.
A contrast to the above is the possibility of a Parkinson-type drug-induced response,
which creates an absence of movement. Individuals will show a slowness of movement
with rigid or stiff muscles and a possible tremor. Shuffling is noted when walking
accompanied by stooped posture and diminished arm swing. Facial expression turns
blank creating a somber appearance. These symptoms may remain long after the
medication has been discontinued.
Communicating with Persons with Tardive Dyskinseia:
Tardive Dyskinesia is not classified as a mental illnesses within itself, however the drugs
that are utilized to treat other mental illness such as schizophrenia can lead to TD. Thus,
communicating with a person with TD should be approached per previously mentioned
guidelines to include de-escalation techniques as needed.
Instructor Note:
A word of caution concerning the extensive movement associated with Tardive
Dyskinesia: Be aware that the quick movements could distract and/or trigger defensive
actions on the part of the officer.
TD can affect a person’s respiratory function in turn having a subsequent effect on
speech patterns. Inflections or tonal changes in the voice could be inconsistent with the
person’s intentions and body language.
Instructor Note: Role-play exercise:
Description of the scene:
Mental Health Peace Officer
Page 43 of 97
June 2008
You are patrolling a normally quiet but “pricey” shopping area in your town. A woman
comes out of the jewelry store and waves your car down. Upon entering the store the
women explains to you that a customer knocked over a very expensive piece of crystal in
the shop and in trying to pick up the remains has cut himself and is causing quite a
commotion. Assessing the scene, you are confronted with a man standing in the midst of
broken glass trying to hold a handkerchief to a badly bleeding hand. You note that he is
having difficulty applying pressure to his hand due to a repetitive jerking of his hands.
Walking closer you also note he is rocking slightly, his eyes are rapidly blinking and you
hear a low humming sound. Utilizing what you have learned, what is your response to the
situation?
2.1.3. List common reasons for a consumer deviating from their prescribed
medication schedule
A continuous problem for law enforcement is mental health consumers not adhering to
their medication regimen. This deviation is the primary cause of crisis concerns.
There are many reasons for deviation from prescribed psychotherapeutic medications.
The most prominent include:
 Side effects
 The stigma associated with being mentally ill, i.e., they don’t want people to
know they have a mental illness
 They start feeling better and think they no longer need the medications
Instructor Note: Right to Refuse Treatment - A person may not administer a
psychotherapeutic medication to a patient who refuses to take it voluntarily, unless the
patient is in need of a medication related to an emergency, or the patient is under an
order authorizing the administration of the medication regardless of the patient’s refusal.
Instructor Note/Class Discussion: Would you want to take these medications? Is the
treatment worse than the illness?
Mental Health Peace Officer
Page 44 of 97
June 2008
3.0. Discuss signs and symptoms of suicide
As a Law Enforcement officer you may encounter individuals who are at a high risk for
suicide. You may find yourself facing a distraught or irrational person posing a danger to
you, themselves or others. A large portion of people arrested are at an elevated risk of
suicide through the abuse of drugs or alcohol or a mental illness not in check. In some
situations you may find the individual antagonistic in hopes of manipulating you in
assistance with their suicide plan (suicide by cop.)
Instructor Note:
Explain the phrase “suicide by cop.”
From a recent briefing paper from the Treatment Advocacy Center (02/20/05):
“People with severe mental illness are killed by police in justifiable homicides at
a rate nearly four times greater than the general public.”
“One study…found that incidents determined to be suicide by cop accounted for
11 percent of all police shootings and 13 percent of all fatal shootings. The study
found that suspects involved in such cases intended to commit suicide,
specifically wanted to be shot by police…provoking law enforcement officers into
shooting them.”
“In 1997, M.P. was driving erratically on the Long Island Expressway. When the
police pulled him over, he brandished what turned out to be a toy gun he had
purchased earlier that day and advanced on them, despite warnings to stop. The
police shot and killed him. They found 10 letters in his car, including one
addressed “to the officer who shot me”. It said: “Officer, it was a plan. I’m sorry
to get you involved. I just needed to die. Please send my letters and break the
news slowly to my family and let them know I had to do this. And that I love
them very much. I’m sorry for getting you involved. Please remember that this
was my doing. You had no way of knowing.”
“Anyone who is thinking about committing suicide needs immediate attention,
preferably from a mental health professional or a physician. Anyone who talks
about suicide should be taken seriously. While some suicide attempts are carefully
planned over time, others are impulsive acts that have not been well thought out...”
(National Institute of Mental Health)
Instructor Note: In a ten year study in Los Angeles, 11% of shootings by law enforcement
officers, and 13% of officer-involved justifiable homicides, occurred in the process of a
provoked shooting. Discuss students experiences on the job with this topic area.
The Mental Health Association of Texas reports:
 Half of all Americans will experience a mental disorder at some point in their
lives
Mental Health Peace Officer
Page 45 of 97
June 2008

4.3 million Texans (3.1 million adults and 1.2 children) had some form of
diagnosable mental health disorder in 2002 (20%)
 There are 1.5 times more suicides than homicides, with an average of 6 deaths
each day by suicide in Texas
 Latest statistics reported in 2001 states that 121 more people committed suicide in
2001 than in 2000. This is a six percent increase in one year. The gender
breakdown was reported at 1,772 males vs. 442 females (i.e., about 4 men for
each woman)
 Highest rates of suicide are in the 45-54 age group (15.2 per 100,000), with the
second being the 75-year-and-older age group (18 per 100,000)
 90% of suicides are reportedly related to untreated or under-treated mental illness
with the most common being depression.
 Nearly 20% of people diagnosed with bipolar disorder and 15% diagnosed with
schizophrenia die from suicide.
Further statistics
 200 people kill themselves each day worldwide
 30,000 in US each year
 300,000-600,000 in US survive a suicide attempt each year, 19, 000 are
permanently disabled as a result of this attempt
 8th leading cause of death in US
 Men four times more common than women
 Caucasian men over the age of 35 are the highest risk group
 Native Americans are one and one-half times higher than the national average
 10% of elderly population and with exponential movement after age 70
 Person less likely to be murdered than to commit suicide
3.1. Explain the process of evaluating suicidal risk
Recognition of warning signs:
An individual considering suicide may try to reach out to you in a direct or indirect
manner. Examples of signs of imminent danger could include the following and are
especially important if the individual has attempted suicide in the past or has a history or
current problem with drugs/alcohol or PTSD.
 Talking about suicide or death
 Giving direct verbal cues such as “I wish I were dead” or “I’m going to end it all.”
 Giving less direct verbal cues such as “What’s the point in living” or “Soon you
won’t have to worry about me.”
 Isolation
 Expressing that life is meaningless/hopeless
 Giving away treasured possessions
 A sudden and unexplained improvement in mood after being depressed or
withdrawn for a length of time
 Neglecting hygiene/personal appearance
Mental Health Peace Officer
Page 46 of 97
June 2008
There is no positive means of identifying immediate risk of suicide however; most
warning signs especially in combination indicate that the individual is experiencing some
sort of emotional stress.
What inner dynamics can make suicide seem sensible?
1. Situational Characteristic: Common stimulus-unendurable psychiatric pain
2. Motivational Characteristic: Common purpose-seek a solution
3. Affective Characteristic: Common emotions-helplessness and hopelessness
4. Cognitive Characteristic: Common cognitive state-ambivalence between doing it
and wanting to be rescued
5. Relational Characteristic: Common interpersonal act-communication of intention,
letting others know it makes sense
6. Serial Characteristic: Common consistency-lifelong coping patterns of deep
distress and psychological pain
Instructor Note: Even though there are commonalities each situation is individual and
there are no absolutes.
Suicidal intervention strategies:
 The three “I’s”:
o Confront situation that seems to be Inescapable, Intolerable, and
Interminable.
o The goal of this intervention is to change one or more of the “I’s” as
quickly as possible establishing a rapport with the individual to provide an
anchor to life.
 Contracts:
o The stay-alive, no-harm contract: simple and to the point with no wiggle
room.
o Self-contract: focuses on anger toward another but that the person’s life is
still important to others.
Instructor Note:
If you are called to a situation where an individual is already deceased as a result of
suicide, you will be utilizing your crisis de-escalation techniques on the family members
and/or friends of the deceased or “suicide survivors.” They may not understand why they
cannot see the body or collect personal belongings such as the suicide note. It will be
your responsibility to explain department policy and procedure on the securing of a
crime scene until the investigation has been completed.
You also may need to contact the next of kin of someone who has committed suicide. It is
advisable to approach this notification with a police chaplain and/or a victim advocate
representative. Notification to the verified primary adults should be made face to face,
not by telephone. Upon contact they will be awaiting bad news so be direct and clear in
your information and be ready for questions and crisis conditions to emerge. Reactions
may be varied and could range from hysterical crying to non-belief. Before leaving
suggest calling a support person (friends, relatives, clergy) to stay with the grieving
Mental Health Peace Officer
Page 47 of 97
June 2008
family and give them your card for later questions and a list of referral sources for
survivor support groups in the area.
Instructor Note:
Resource for finding suicide survivor support groups:
http://www.suicidology.org/associations/1045/Support_Groups.cfm.
http://www.afsp.org/index-1.htm.
3.1.1. Evaluate the risk of suicide by the Law Enforcement Officer
Law Enforcement officers are also categorized as high-risk for suicide due to their
occupational conditions. They are more prone to the risk of divorce, alcoholism,
emotional/physical problems and Post Traumatic Stress Disorder (PTSD), which are all
contributing factors in the risk of suicidal behaviors.
Another cited reason experts believe law enforcement officers are a high risk of suicide is
the innate nature of the police culture. Control command presence are essential
components of the job itself. It is often seen by peers and superiors as weak if help for
emotional issues is requested. This misconception can affect an officer’s sense of self
confidence and their relationship/trust level with their team.
Officers also have a means of suicide at their disposal; a firearm. This access may
contribute to the increase in the risk of dying by suicide.
Other warning signs that have been identified as “red flags” in officer suicidal behaviors:
 Announce that they are going to do something that will ruin their careers, but they
don’t care.
 Admit that they feel out of control
 Appear hostile, blaming, argumentative, and insubordinate OR appear passive,
defeated, and hopeless.
 Develop a morbid interest in suicide or homicide
 Indicate that they are overwhelmed and cannot find solutions to their problems
 Ask another officer to keep their weapon, inappropriately use or display their
weapon, or carry more weapons than necessary
 Begin behaving recklessly and taking unnecessary risks
 Deteriorating job performance
Instructor Note:
Class discussion: If you suspect that another officer is thinking of harming themselves,
ask directly, in private, if this is the case. If the officer admits or denies and you still have
a concern, the following steps should be initiated:
 Express concern to supervisor or department’s mental health professional
 Refer the officer in need to the National Suicide Prevention Lifeline at (800)273TALK (8255).
 Offer to assist finding or accompanying officer to a mental health professional for
assessment
Mental Health Peace Officer
Page 48 of 97
June 2008

Assist the officers support structure for crisis assistance
Scenario: Tony is a seven-year veteran uniformed police officer. He recently applied for
a position that would involve a promotion. Before the morning roll call, Tony’ shift
supervisor, Javier, thought that Tony looked out of sorts and anxious.
When he had a chance to talk to Tony in private, Javier asked him if he had heard
anything about the new job. Tony replied, “I think I’m going to withdraw my application.
It just doesn’t matter any more.” Javier asked why and Tony said that his wife had just
filed for divorce and was asking for full custody of their two children. Javier suggested
that Tony talk to a mental health professional, but Tony was reluctant; he had never seen
a counselor or psychologist. Javier admitted that he had seen a therapist after he shot a
teenager a few years ago. Javier told him that even though the shooting was justified, it
really shook him up, and talking to someone really helped. Javier offered to make an
appointment for Tony and to go with him to the appointment if Tony wanted his support.
Tony appeared relieved and took Javier up on his offer.” (Scenario reference: Suicide
Prevention Resource Center).
General resources on suicide and suicide prevention:
Suicide Prevention Resource Center: http://www.sprc.org/
National Center for Injury Prevention and Control: http://www.cdc.gov/ncipc/
COPLINE: [email protected]
The National P.O.L.I.C.E. Suicide Foundation: http://www.psf.org/
Mental Health Peace Officer
Page 49 of 97
June 2008
4.0. Explain Crisis Behavior and its relevance to CIT Training
“As a law enforcement officer, you are often called into action when something is wrong:
when someone has been assaulted, robbed, or injured or when there is a confrontation or
the threat of a confrontation. You interact with people who are angry, emotional, injured,
frightened, or traumatized. Some of these people welcome your presence, while others
resent it. You face situations that are, or could easily become, violent and threaten you,
your fellow officers, and members of the public with injury or death. Many of these
incidents involve complex interpersonal and legal situations in which you must protect
yourself and others while maintaining your authority and respecting the rights of the
public.”
Instructor Note: Above reference: Suicide Prevention Resource Center
4.1. Discuss the cycle of crisis behavior
Defintion of Crisis Behavior:
 A person suffering from a temporary breakdown in coping skills that includes
perception, decision-making, and problem solving abilities
 Different depending on individual response.
 Anyone can suffer from a crisis and its effects can vary with time, place, and
person
 Examples: Being locked out of the house, losing a job, being a victim of a crime,
having a divorce, being involved in a traffic stop or accident
Crisis Escalation Cycle:
As an individual enters into a crisis situation their response enters into fairly predictable
stages. If acutely psychotic, responding to internal stimuli, or intoxicated, these stages
will vary and may become even more erratic.
Instructor Note:
How do people move through a crisis situation? Illustrate on a whiteboard or flip chart
as discussion of crisis escalation cycle progresses. Guide class in selection of a crisis
situation to apply to the crisis escalation cycle example. Utilize this example throughout
this discussion.
Crisis Cycle:
1. Onset: (Select class example of a crisis situation)
Incident or Occurrence causing a person to become excited, active, upset, or physically
uncomfortable
 Cause or stimulus could be:
o External:
 Words or behavior of another person
Mental Health Peace Officer
Page 50 of 97
June 2008
 The environment (crowded, cold/hot)
o Internal:
 Physical illness or pain
 Emotional upset
 Mental illness (internal stimuli)

Note: Regardless of the source, capacity to understand verbal information decreases 50
to 75 %.
2. Escalation and Anger: (List signs and changes applicable to class example)
 Obvious signs of distress and observable changes (physically and behaviorally)
begin to occur
o Red face
o Tense muscles (tight face, clenched fists)
o Talking more and/or louder or quiet and withdrawn
o Increased activity (pacing, rocking, etc.)
Note: Movement from anger to hostility produces another drop in comprehension to 525% of normal rate.
3. Out of control behavior: Discuss behavior attributable to class example
 Aggression
 Screaming and yelling
 Throw or hit things
 Assaultive actions
Note: Comprehension level from 0-5% of normal rate and as a result individual is unable
to follow directions.
Important: Interruption in cycle can occur at any stage, however when they begin to deescalate, their comprehension remains impaired. If they are provoked they can quickly reescalate to the crisis stage.
4.1.1. List examples, for officer response, at each level of escalation
Officers are not infallible and their communication can also be affected as a result of the
crisis cycle.
Escalation of violence chart depicting possible officer response:
Mental Health Peace Officer
Page 51 of 97
June 2008
PERSON
OFFICER
Level 4: Violence Anger/Fear
Level 3: Hostility
Fear
Level 2: Anger
Anxiety
Level 1: Anxiety
Empathy
Calm
Supportive
The above chart depicts the interaction/dynamics between an individual and an officer.





During the calm state, the individual is easy to interact with, even if experiencing
perceptual distortions (hallucinations).
At level 1, still relatively easy to interact with the individual and even responds
with a degree of empathy.
At level 2, the individual begins to show progressive signs of anger and the
officer begins to show signs of anxiety.
At level 3, hostility begins and officer response turns to fear.
At level 4, the individual is showing open aggression and abusive behavior and
the officer responds through anger and fear.
Instructor Note:
Discuss how an individual traditionally responds to the emotion of fear.
Not only is the person in crisis moving up the escalation of violence scale but likewise
the officer’s behavior tends to reciprocate causing effective communication to diminish
on both sides. This result is being counter productive to the task at hand.
Goals of officer:
 Suspend emotions temporarily to listen for emotional cues in an effort to be
effective
 Guide the crisis individual into a stage more conducive to communication and
interchange
 Utilization of prior training and experience acquired for stressful situation
scenarios
Instructor Note: The following is an extended version of the escalation of violence chart.
This can be utilized for role play, discussion groups etc. when discussing the topic of the
cycle of crisis.
Level 1: Anxiety
 Feelings associated with anxiety are dread and helplessness. These feelings are
subjective but none the less uncomfortable.
 Goals for officer: provide support to restore the individual’s sense of control.
Discuss alternative solutions to perceived crisis. Techniques include:
o Face person squarely
o Model an open and relaxed posture
Mental Health Peace Officer
Page 52 of 97
June 2008
o
o
o
o
Lean towards person without entering personal space
Maintain direct eye contact
Attempt to control environment for purposes of de-escalation
Active communication/listening skills (paraphrasing, “I” statements,
effective silence, open statements, allow for venting etc.)
Level 2: Anger
 “Feeling” anger may serve to reduce the dread of anxiety and bring the person a
sense of power or control. This “feeling” however, can quickly escalate into
physical expression if not held in check.
 Thought processes change becoming more concrete, less flexible and more nonverbal with visual communication becoming more important.
 Goals for officer: keep person talking to you and utilize this time to de-escalate.
Techniques to implore:
o Diffuse the adversarial response by acknowledging the individuals anger
surrounding the crisis situation. Note: Acknowledging their feelings does
not show you necessarily agree with them only that you understand its
existence.
o Provide assistance in solution oriented behavior, by offering options,
choices, and eventually consequences for decisions.
o Active communication/listening skills as above but utilize a 45 degree
stance for safety purposes.
Level 3: Hostility
 Hostility is anger focused on a target. It is recognizable by feelings such as:
irritability, argumentative, demanding, antagonistic and oppositional behaviors
accompanied by loud and threatening verbal and non-verbal communication.
 Exercise caution due to rapid transition time from anger to violence.
Goals for officer: obtain immediate control of the situation through a series of quick
intervention techniques to include:
o Clearly state acceptable boundaries
o Be professional and clear in your non-verbal communications
o Be consistent in tone, volume and message
o Utilize short sentences and repeat as needed
o Attempt to diffuse the adversarial stance by:
 Acknowledging anger
 Dialogue, moving to a more de-escalated manageable stage
 Firmly give directives if no response
 Give warning if de-escalation techniques are unsuccessful by
stating clearly the consequences of the current course of action.
 Monitor your own response: take deep breathes, approach person
from side but keep open posture to avoid being perceived as
confrontational. Maintain eye contact and authoritative stance to
convey control and do not attempt to touch the individual.
 Utilize continual communication to warn of possible attack
Mental Health Peace Officer
Page 53 of 97
June 2008



Do not engage in accusations or arguments. (This would give
control to other person and create power struggle.)
Address only behaviors that interfere with safety of individual, self
or others
Only state consequences or promises that can be followed through.
Level 4: Violence
 Violence is aggression with a target on destruction with a goal of injury
 Violence may be through verbal or physical interaction
Goal of officer: Safety, protect yourself and others Techniques to assist:
o Remain at 45 degree stance
o Don’t make sudden moves
o Don’t take insults or accusations personally or be baited into doing so
o Maintain eye contact but clearly indicate that you intend to disengage by
moving back slowly
o Remaining at a safe distance and protected until back up arrives.
4.2. Discuss officer interactions with persons who have a mental illness
Behaviors associated with mental illness will depend on a number of indicators, to
include but not exclusively:
 The nature of the illness
 The severity of the illness
 The personality of the individual
 Other influences (intoxication, medication usage etc.)
Although no one indicator will tell you if a person has a mental illness, some general
characteristics associated with mental illness could include:
 Behavior or mood that is inappropriate to surroundings or situation
 Inflexible and/or impulsive behaviors
 Lower tolerance for stress which may result in exaggerated responses
The following is a list of basic strategies that are necessary when communicating in crisis
situations.






Stay calm - breathe deeply to become calmer
Be patient - avoid “crowding” the individual, give them time to calm down
Double-check information by restating what you hear
Use the individual’s name in talking to them
Give instructions or directives one at a time, and allow time for the person to
comply
The size and age of a person with mental illness has little to do with whether a
back-up officer should be called, a person with a mental illness may exhibit
extraordinary strength. Call for back-up.
Mental Health Peace Officer
Page 54 of 97
June 2008







Engagement is pivotal - keep trying
Don’t underestimate the power of hallucinations or delusions - they are real from
the individual’s point of view and can be very frightening, so try to be
understanding
Never argue about a delusion, since arguing only solidifies the conviction simply accept and move on
Ask about treatment in the past - sometimes that can help with offering potential
solutions to the current situation
Remember that psychotherapeutic medications have side effects that make them
hard to take. Do not take a judgmental stance.
Don’t express disapproval
Persons in mental health crisis need more personal space - watch for cues
Obtaining information from the individual in crisis can sometimes be a difficult situation.
The following questions may assist in this endeavor.
1.
2.
3.
4.
5.
6.
7.
What is your name?
Where do you live? Where have you been sleeping?
Can you tell me where you are right now?
What is the date, month, day of week, time of day?
When did you last eat?
When did you last sleep and for how long?
Have you been using any alcohol or substances? What? How much? When did
you last use?
8. Do you hear voices that other people cannot hear? What do the voices say to you?
9. Do the voices tell you to hurt yourself or other people?
10. Are you thinking about hurting or killing yourself?
11. What kind of problems are you experiencing?
12. Are you supposed to be taking any kinds of medications?
13. When was the last time you took your medications?
14. Do you see a doctor or other professional for treatment? Who do you see? When
did you last see this professional?
15. How do you support yourself? Are you on SSI? If so, what for?
16. What are you afraid of?
17. Do you suffer from a mental disorder?
18. What do you think would be helpful to you right now?
19. Are you able to control yourself at this time?
Instructor Note:
Hand out copies of the following information to class members. Divide into groups and
instruct students to practice role-playing a crisis situation utilizing the reviewed
techniques.
1. Safety - Your personal safety comes first. Control the surroundings. Remove
harmful obstacles from the surroundings.
Mental Health Peace Officer
Page 55 of 97
June 2008
2. Crisis facts - The person in distress is usually excited, alarmed, or confused.
Control is very important to persons in crisis. When people feel cornered, which
translates to lack of control, they may respond with sudden violence.
3. Language - Use the person’s name. Talk quietly. Speak firmly. Use a calm tone of
voice. Avoid direct confrontation. Avoid labels and acronyms. Limit the number of
instructions, and give them one at a time. Be patient and consistent. Reactions
and verbal responses may be slower than you expect.
4. Movements - Be aware of body movements. People in crisis often need more
physical space. If possible, position yourself at or below the individual’s eye level.
Keep all movements slow and deliberate.
Helpful Hints:
Ask the person about available supports, e.g. clergy, family, therapist, doctor.
Don’t be afraid to reveal your own emotions, e.g. “Mr. Smith, you’re making me
nervous.” Introduce yourself clearly. You may need to re-introduce yourself
multiple times. Try to find ways to establish trust. Keep your own emotions under
control. Allow ventilation. Reassure, but be realistic, don’t lie. Listen actively.
4.3. Explain how to utilize observation as a tool for evaluative purposes
Observation is a vital tool in evaluating an individual or a situation. Examples of the steps
of observation and appropriate terminology are as follows. These will be helpful when
documenting the situation in your report:
1. Consciousness: the degree to which a person is aware and responsive to their
environment. Such as:
 Delirium, stupor or coma indicates: Lowest level of consciousness. This
level could indicate an organic or physical issue or a medical emergency
 Inattention: creates difficulty in gaining and maintaining the individual’s
interaction
 Distractibility: a state in which a person’s attention can easily be diverted
due to another stimulus.
 Confusion: impaired understanding of a person’s surroundings.
2. Activity: movement or motor activity which could be at an inconsistent or unusual
level.
 Restlessness or the state of constant movement. Note: this may be a result of
medications.
 Agitation: restlessness associated with extreme anxiety
 Delayed reaction or very slow movements: common in depressed persons or
those under the influence of sedating substances.
 Repetitive activity: that do not seem to serve a useful purpose.
 Compulsive activity which is obsessive repetitive movement.
3. Speech: the content and process of speech
 Accelerated or slowed
Mental Health Peace Officer
Page 56 of 97
June 2008




Unusual in rate, volume or tone
Neologisms or words made up by the person that have no real meaning in our
language
Themes which are paranoid or delusional in content
Echolalia: echoing words
4. Thinking: disordered in content and/or progression. Lack of integration of
knowledge, perception and memory in thought processes.
 Progression of thought may be accelerated or decelerated
 Thought process may indicate a logical or illogical flow acknowledged by the
process of ideas connecting from one to another in an organized and
consistent manner.
 Circumstantial thought process: ideas are logically connected but do not flow
from one to another in an organized manner. Though the person eventually
connects thoughts it is in a round about fashion.
 Tangential thought process: ideas appear logically connected but lose
association as proceeds on a tangent to other thoughts.
 Thought blocking: ideas are logically connected but person finds difficulty
moving to next thought.
 Loose associations: two ideas may be logically connected but they are not
connected with the next idea in a logical way.
 Flight of ideas: accelerated thinking where none of the thoughts seem to be
connected in any way.
 Perseveration: a repetition of an idea over and over again.
 Abnormal thought content indicative of a mental illness includes:
o Delusions (Paranoia, Grandiosity, Religiosity)
o Thought broadcasting (others can hear your thoughts)
o Ideas of reference (events/objects have a meaning specifically for that
person)
o Thought control (outside forces are controlling thoughts)
o Obsessions (fixated thoughts that will not go away)
o Homicidal/suicidal ideations (thoughts of wanting to kill themselves or
others)
5. Affect and Mood: outward expression of a subjective feeling.
 People with a mental illness have the same feelings as anyone else but they
tend to differ in their extremeness, appropriateness and fluctuation.
 Affect tends to be incongruent with the situation, shifting from one emotion to
another or to no expression at all (flat.)
6. Memory: complex function consisting of four separate functions.
 Registration: ability to add new information to the cerebral data bank
 Retention: ability to retain or store information for later retrieval
 Recall: ability to retrieve information on demand
 Recognition: ability to identify information from past knowledge
Mental Health Peace Officer
Page 57 of 97
June 2008

One or a combination may be impaired.
7. Orientation: a persons sense of:
 Who they are (person)
 Where they are (place)
 At what point in time it is (time)
 Disorientation (associated with organic or physical impairments)
 Delusional (disoriented, believing they are someone else)
8. Perception: way in which a person processes data provided by the five senses
 Hallucinations: perceptions that have no basis in reality and may occur in any
of the five senses.
 Auditory hallucinations are most common
 Hallucinations may also be associated with organic or physical problems such
as drug intoxication or withdrawal.
9. Physical symptoms could also assist you in identification of a person’s problem
area
 Examine the skin: temperature, moisture, needle marks etc.
 Be aware of the eyes: pupil size, equality and reaction to light which can
indicate toxic ingestion or intracranial issues
 Rate of breathing and unusual odor to breath
 Extremities: needle marks, tremors, unilateral weakness, loss of sensation
Note: From “Crisis Intervention Strategies.” See reference section.
4.3.1. Discuss additional ways to obtain useful information for evaluative purposes
In addition to your personal observations, it is important to obtain information from
witnesses and family members and friends. The following is a list of questions that could
be utilized in obtaining information from these sources:
1. Is the individual in treatment for a mental illness? If so, when and where are they
receiving treatment?
2. Has the individual ever been hospitalized for a mental illness? Where and when?
3. Is the individual taking any medications for a mental illness? If so, what are they
taking and when did they last take it?
4. Has the individual been using any alcohol or non-prescribed substances?
5. Has the individual threatened or attempted violence toward self or others?
6. Has the individual been neglecting personnel hygiene or bodily functions like
eating or sleeping?
7. Have any traumatic or crisis events recently occurred?
Instructor Note:
Mental Health Peace Officer
Page 58 of 97
June 2008
Law Enforcement Officers can interact with mentally ill persons in the capacity of
victims, offenders, witnesses, and/or bystanders; remember that each will respond
differently to perceived threats, especially in a crisis state.
Six step model of Crisis Intervention:
1. Defining the problem: define and understand the consumer’s point of view. If not
perceived the same, intervention strategies won’t work.
2. Ensuring client safety: Minimizing the physical and psychological danger to self
and others.
3. Providing support: Communicate to client that you care.
4. Examine alternatives: Exploring appropriate choices available that are realistic for
the situation.
5. Making Plans: Planning action steps that have a chance of restoring client’s
emotional equilibrium.
6. Obtaining commitment: If planning stage is done effectively, buy-in is easy. Ask
them to explain the plan back to you before terminating contact with them.
Instructor Note: Refer to “Crisis Intervention Strategies” by Richard James for expanded
process of this model. (See References)
Why do we need to assess?
Assessment enables you to determine:
 The severity of the crisis
 The consumers current emotional status
 The alternatives, coping mechanisms, support systems, resources available
 Consumers level of lethality (danger to self and others)
Questions to ask your self when assessing individuals state of crisis:
 How realistic and consistent is the clients thinking about the crisis?
 To what extent does the individual appear to be rationalizing, exaggerating, or
believing part-truths to exacerbate the crisis?
 How long has the individual been involved in the crisis thinking?
 How open to changing beliefs about the situation and reframing to more rational
thoughts?
 What degree of emotional stamina or emotional coping is left at the individual’s
disposal?
 Is this an acute or situational crisis?
Questions to ask your self concerning your actions:
 What realistic actions can you take?
 What institutional, social, vocational, or personal (people) supports are available?
 Who cares and could assist? Are there financial, social, vocational, or personal
impediments to individual’s progress?
Techniques for positive listening :
Mental Health Peace Officer
Page 59 of 97
June 2008






Ask open ended questions: start with what, how, or ask for clarification or details.
Stay away from why questions.
Close ended questions when desiring concrete answers: used initially to gain
specific information. Use do, did, does, can, have, had, will, are, is.
Restatement and summary: Used for clarification and agreement
Owning feelings: Used to model behavior
“I” statements: Conveys that you understand situation that is causing distress.
Also an owning statement.
Silence: do not feel compelled to talk. Individuals need time to think. Remaining
silent but showing interest and empathy conveys you care.
Instructor Note:
Rapid and constant assessment of the individual’s current state of equilibrium dictates
what the interventionist will do in the next seconds/minutes as the crisis unfolds.
Remember: events occur quickly.
Remember: Every crisis has a hidden potential for a violent act (suicide/homicide). What
appears to be the problem may be camouflaged.
4.4. Demonstrate how Crisis Intervention Techniques can be utilized in domestic
disturbance situations.
Instructor Note: Show the video on Domestic Disturbances. Upon completion, discuss
the tactics and techniques that can be used effectively in domestic disturbance situations
based on the scenario shown on video.
4.5. Discuss emerging trends in Crisis Intervention techniques
Emergent directions of the Crisis Intervention Movement
1. Has evolved into a major human service sub-specialty
2. Has become widely apparent that a reactive approach to crisis intervention is not
enough; proactive and preventive models need to be developed and implemented
Why has the Crisis Intervention Movement grown?
 No single factor
 In US: Bombing of the federal building in Oklahoma City, Twin Towers,
school shootings, Washington DC beltway snipers, and random acts of
terror.
 Globally: Poverty, war, population explosion, drugs, HIV and other
pandemic diseases, immediacy and power of the media to stir emotions
and demand actions, environmental movement, increased mobility of
people, technological advances, rise in crime and terrorism.
 Need to face everyday issues in communities, families, work
environments, schools and streets.
 Theories’, methodologies and strategies of crisis intervention have come
to be viewed as legitimate in both society and the mental health field.
Mental Health Peace Officer
Page 60 of 97
June 2008

Communities have become more positive in their acceptance and view of
strategies and see as more cost effective.
Emerging trends
 Proactively: Planning for future directional needs
 Psychiatric emergency and stabilization programs
 Integrated emergency management system from local to national level
 Electronic outreach programs
 Debriefing procedures for response workers
Instructor Note:
Discuss these emerging trends and add to this list from student’s participation.
Mental Health Peace Officer
Page 61 of 97
June 2008
Unit Goal: 5.0. To explore the world of the mentally ill through a discussion of legal
and societal concerns and perspectives.
A person with a mental illness may harm other citizens by committing personal or
property crimes or engaging in disorderly and disruptive behavior. Alternately, a person
with a mental illness may be harmed as a crime victim, as an abused family member or
patient, as a person who suffers through self-neglect, or as a person whose mental health
problem has left them erroneously subjected to criminal charges and jail confinement.
5.1. Discuss the mentally ill person in the situation of being homeless.
On any given night approximately 600,000 Americans are homeless, and more than 2
million people are homeless throughout the year. According to conservative estimates,
one-third of the people who are homeless have a serious mental illness, and more than
one-half also have a substance abuse disorder.
Vast increases in homelessness seem to have occurred in the 1980s when housing options
for lower income individuals became an issue. Today however, a new wave of homeless
mentally ill persons has emerged. This new homelessness is the long-term result of
deinstitutionalization, denial of mental health services due to funding cuts, and premature
discharge from treatment options due to managed care.
Persons with mental disorders remain homeless longer due to:
 Isolation from family and friends,
 Barriers to employment
 Low income status
 Poor physical health
 More contact with the legal system
5.2. Discuss the mentally ill individual as a victim of crime.
“People with mental illness are more likely to be victims than perpetrators of violence”
- National Institute of Justice, 1996
Why then is … thirteen times more research compiled concerning the mentally ill as
perpetrators of violent acts rather than as victims of violent acts? (see the Archives of
General Psychiatry, August 2005)
Statistics:
 4-13% of mentally ill consumers are perpetrators of crime
 Mentally Ill consumers are 140 times more likely to be victim of theft
 3 million Mentally Ill consumers are estimated to be victimized each year
 In a year, more than one-quarter of mentally ill consumers say they are victimized
The public tends to be surprised by these findings. Due to the stereotype that people with
a mental illness are dangerous, these statistics may seem surprising. Violence among this
Mental Health Peace Officer
Page 62 of 97
June 2008
population is caused by many of the same factors that produce violence in the rest of
society. People become violent when they feel threatened, when they feel out of control,
or with the excessive usage of mind-altering substances.
“We don’t think about their vulnerability to victimization.”
- Alison McCook, Reuters Health
“People with mental illness are more vulnerable to crime than others. They often live in
poor communities and areas with higher crime rates. They may be unable to make safe
decisions, such as avoiding an empty, dark street.”
- North Western University
“The effect of crime is also more destabilizing with a person with mental illness.”
- Dr. Linda A. Teplin
Tips for responding to victim needs:
 Victim’s need to feel safe - people feel helpless, vulnerable and afraid by the
trauma of their victimization.
 As a law enforcement officer, you are usually the first to approach the victim how the officer responds to the victim is very important
 Victim’s need to express their emotions - victims need to air their emotions
and tell their story after the trauma of a crime, and they need to have their
feelings accepted and their story heard non-judgmentally
 Victim’s need to know what comes next - the officer can help relieve some of
the anxiety by telling victims what to expect in the aftermath of the crime,
which will help prepare them for the upcoming investigation process
Characteristics of the Mentally Ill consumer and victimization:
 Children with mental illness may be molested or abused. They are often unable to
identify the suspect.
 Adults with a mental illness may be easily robbed or become a victim of a con
artist.
 A person with a mental illness has the same chance of being victimized as the
general public, but they reportedly have less chance of a successful prosecution.
Instructor Note:
Mentally retarded victims of crime will need special consideration upon approach. This
population may not even know they have been victimized, due to their naiveté and lack of
ability to discriminate between a good and bad social situation. Mentally retarded
victims are also easily fooled and become easily vulnerable. These victims, just as with
mentally ill victims, will need to be treated with extreme patience and respect.
The way people cope as victims of crime depends largely on their experiences and on
how others treat them immediately after the crime. As a law enforcement officer, you are
usually the first official to interact with victims. For this reason, you are in a unique
Mental Health Peace Officer
Page 63 of 97
June 2008
position to help victims cope with the immediate trauma of the crime as well as to help
them regain a sense of security and control over their lives.
The responding officer’s awareness of the needs of victims, the many dimensions and
consequences of crime for victims, common responses to victimization, and the particular
needs of distinct victim populations can help the officer avoid a re-victimization of
victim.
Anyone who is a victim of crime may be traumatized and experience the victimization as
a crisis. But for people with a mental illness, this crisis may be experienced more
profoundly.
5.3. Evaluate the stigma and societal discrimination that exists toward persons who
are mentally ill.
Stigma is a mark of disgrace or shame. It is made up of various components, including:
 Labeling someone with a condition
 Stereotyping people with that condition
 Creating a division (i.e., a superior “us” and a denigrated “them”)
 Discriminating against someone on the basis of their label
Stigmas encourage inaccurate perceptions. The term mental illness in itself alludes to
false information. “Mental” suggests an illegitimate medical condition that is “all in your
head,” and therefore a sign of weakness. The term “mental” suggests a separation from a
physical illness, when in fact they are entwined. Studies reported on MayoClinic.com
show that there is in fact a physical change in the brain associated with mental illness,
suggesting that a biological basis exists.
It is also a common stereotype that persons with a mental illness are dangerous and
unpredictable, although statistics do not substantiate the idea. Sigma’s continues to be
believed. They are stereotyped as somehow less competent, that they are not able to
work, and that they need to be institutionalized to “get better.”
These stigmas perpetuate a negative portrayal of people with a mental illness that fuels
fear and mistrust, and reinforces a distorted perception, which leads to further stigma and
devastating consequences. Some people refuse treatment for fear of being “labeled.” The
stigma can lead to social distancing due to shame and embarrassment.
Discrimination in the workplace reportedly continues, even with the American with
Disabilities Act in place. Victims may lose jobs through the stress of coworker gossip and
experience a lack of promotions. The stigma even extends to the medical community,
where health insurance coverage is more limited for mental illnesses than for physical
illnesses.
Dispelling prominent myths regarding mental illness can reduce undeserved stigma.
Mental Health Peace Officer
Page 64 of 97
June 2008
Consider the following:
Myth: Mental illness does not affect the average person.
Reality: No one is immune to mental illness. More hospital beds are filled by individuals
with mental illness than those with cancer, heart, and lung disease combined.
Myth: Mental illness is an indication of a weakness of character.
Reality: A combination of factors contributes to mental illness, including malfunction of
neurotransmitters, heredity, stress, and recreational drug usage.
Myth: A person with a mental illness is also mentally retarded.
Reality: There are some persons with a co-occurring, but the conditions are
fundamentally different.
Myth: If you have a mental illness, you are “crazy” all the time.
Reality: Mental illness is often temporary. People suffering from even the most severe
mental illness are in touch with reality as often as they are actively psychotic.
Myth: If people with physical disabilities can cope on their own, people with mental
illness should be able to do so as well.
Reality: Most people who have a disabling illness need help to return to normal
functioning. Physical therapy fills this role for a physical illness just as therapeutic
rehabilitation is needed for a mental illness.
Myth: Most people who struggle with mental illness live on the streets or are in mental
hospitals.
Reality: About two-thirds of Americans who have a mental illness live in community
settings.
5.3.1. Discuss the Americans with Disabilities Act as it relates to individuals
diagnosed with a mental illness
“The Americans with Disabilities Act (ADA) entitles people with disabilities to the same
service and protections that police departments provide to anyone else. They may not be
excluded or segregated from services, denied services, or otherwise provided with lesser
services or protection than are provided to others.”
“The ADA does not call for a fixed set of rules to be followed in all cases involving a
person who has—or exhibits symptoms of mental illness. Rather, the ADA calls for law
enforcement agencies and personnel to make reasonable adjustments and modifications in
polices, practices, or procedures on a case-by-case basis. For example, if a person
exhibits symptoms of mental illness, expresses that he or she has a mental illness or
requests accommodation for a mental illness (such as access to medication or water),
officers and call-takers may need to modify routine practices and procedures, take more
time or show more sensitivity to extend the services or protections that would be
extended to someone else in similar circumstances.” (Police Executive Research Forum)
Mental Health Peace Officer
Page 65 of 97
June 2008
5.4. Discuss legal and societal concerns from a mental health consumer’s vantage
point.
Instructor Note:
Instructors are encouraged to provide a mental health consumer to speak to the officers
about their experiences with the legal and mental health systems. The goal of this section
is to sensitize the officer to the lives, feelings, and thoughts of a person with a mental
illness and their perspective on communication with law enforcement.
**If speaker resources are unavailable, contact the local office of the National Alliance
for the Mentally Ill (NAMI).
5.5. Participate in a discussion of the family member perspective on mental illness.
Instructor Note:
Instructors are encouraged to invite family members of mental health consumers to speak
on their experiences with mental illness and the “system.” The goal is to acquaint the
officer to the experiences and difficulties families face on a daily basis. Speakers can be
obtained by contacting your local office of the Alliance for the Mentally Ill (AMI), or by
contacting the National Alliance for the Mentally Ill.
**In lieu of speakers a video could be used. A resource for obtaining subject matter
videos is The Mental Illness Education Project at www.miepvideos.org.
The following excerpt is from: “Fear and Grief in Dealing in Dual Diagnosis Families”
by Mark Mercer, M.S., LPC. Conduct a discussion after excerpt is shared with class.
“The presence of a disturbed individual leads to disturbance in every family member, no
matter how old or how young-even infants who absorb the whole toxic atmosphere.
Family members fear for the safety and stability of the entire family system and for each
person in it.”
“Unpredictability and potential crisis make every decision, every corner turned, every
encounter with the “sick” one a matter of preoccupation and can quickly dominate the
moods, thoughts, and actions of each individual. It becomes most difficult to focus on any
forward motion, to proceed with life as usual, because “usual” has disappeared into a
swirling quagmire of dysfunction and inertia.”
“Families fear the ringing of the phone, the relentless ticking of the clock when their
loved one is late returning home, the knock at the door by a police officer, the email or
phone call of a school principal, or the notification that they are needed at the hospital.
Long term planning becomes impossible, and highly tentative short term planning
becomes the only option.”
Mental Health Peace Officer
Page 66 of 97
June 2008
“Families may even fear for their own safety, as the person they have loved and known
becomes difficult to love and a stranger they can no longer know. But mostly they fear for
the safety of the patient.”
“They cringe at the real possibility that the one they love is permanently limiting their
options for a secure, happy life, a fulfilling career, an adequate income, friendships, and
a stable place in the family. Most of all, they dread the possibility of death,
institutionalization, or incarceration. And deep inside, they recoil at the thought of
becoming permanent caretakers for an unpredictable, out of control adult.”
“They feel this may be an everlasting tunnel with no light at the end.”
“Despite their sometimes belligerent protests, the patients may be the most frightened
persons in this whole scenario. They are lost in the most profound sense of that word.
They don’t know who they are, where they are going, what they want, why they are acting
as they do, how to manage their minds or emotions. They don’t know how to stop being
crazy, and they can’t trust those trying to help them.”
“Feeling isolated among those that love them, they may seek the solace of other lost
people, that is, if they are not hibernating in their rooms or in a deserted house. This of
course only magnifies and multiplies their problems, as their crippled support group
teaches them new ways to limp. If addiction is not the problem that brought them here in
the first place, they are now more likely to accept it as a solution.”
Mental Health Peace Officer
Page 67 of 97
June 2008
6.0. Develop an increased understanding of the legal process; evaluation and
techniques for appropriateness of apprehension per Texas Health and Safety Code
(Mental Health Code.)
Instructor Note:
Hand out copies of Chapter 573 from the Texas Health and Safety Code to discuss legal
issues surrounding mental health concerns.
6.1. Discuss the process in evaluating the appropriateness of a warrant less
apprehension.
“Least restrictive alternative” is the process that:
 Is available
 Provides the consumer with the greatest possibility of improvement
 Is no more restrictive of consumer’s physical or social liberties than is necessary
to provide the consumer with the most effective treatment and to protect
adequately against any danger the patient poses to himself or others.
Instructor Note: Per Texas Health and Safety Code
6.1.2. Describe the step by step process of Apprehension by a Police Officer without
a warrant to include emergency apprehension.
Instructor Note: Refer to the following references.
Reference: Texas Health and Safety Code, Sec.573.001
Reference the Texas Health and safety Code, Sec .573.002
Reference the Texas health and safety Code, Sec.573.011
Reference the Texas health and safety Code, Sec.573.012
Reference the Texas health and safety Code, Sec.573.021
Reference the Texas health and safety Code, Sec.573.022
Reference the Texas health and safety Code, Sec.573.023
6.1.3. Discuss the Orders of Protective Custody process
Reference the Texas health and safety Code, Sec.574.021
Reference the Texas health and safety Code, Sec.574.022
Reference the Texas health and safety Code, Sec.574.023
6.1.4. Research departmental policies in requesting assistance and transport of a
consumer before and after apprehension
Instructor Note: Departmental policies and procedures should be discussed in regard to
the Texas Health and Safety Code guidelines. Review policy from student’s respective
agencies or refer student to appropriate resources.
6.1.5. Propose justifications in assessing proper use of force option.
Mental Health Peace Officer
Page 68 of 97
June 2008
Use of Force:
 Keep the situation in perspective
 The officer may use force comparable to any other legal duty when a person is
resisting arrest
 The force must be reasonable
 Goal is to obtain care and treatment for the mentally ill person
Reference: Texas Penal Code, Sec.9.51
Instructor Note:
Review the following information with class for discussion purposes.
Changes in the behavior intensity level are also indicators of an individual heading
toward violence:
 Agitated Behavior - trying to keep feelings inside but begin displaying such
behaviors as pacing, hand wringing, hair pulling, etc.
 Disruptive Behavior - outward displays of behavior to include shouting, swearing,
and refusal to comply with requests
 Destructive Behavior - begins to damage items in the environment. Physical
force will probably be needed to intervene depending on circumstances
 Out of Control - individual is a danger to himself and others. The individual is
out-of-control psychologically and is being threatening. Deadly force may be an
option.
6.2. Explain an officer’s limitation of liability.
Limitation of liability:
People acting in good faith, reasonably and without negligence are not civilly or
criminally liable.
Reference: Texas Health and Safety Code, Sec. 571.019 (a)
Instructor Note; Instructor should provide a copy of this section of the Texas Health and
Safety Code to the students.
6.3. Discuss Confidentiality as it relates to the topic of Mental Health and Law
Enforcement involvement
Confidentiality:
 Communication between a patient and a professional, as well as records of the
identity, diagnosis, evaluation, or treatment of a patient that is created or
maintained by a professional, are confidential.
 Exceptions include:
o Disclosure to medical or law enforcement personnel if there is a
probability of imminent physical injury by the patient or others, or there is
a probability of immediate mental or emotional injury to the patient
o When the patient consents
Mental Health Peace Officer
Page 69 of 97
June 2008
o To health care personnel of a jail if it is for the sole purpose of providing
health care
o “Memorandum of Understanding” (refer to the definition section of the
IRG)
Reference: Texas Health and Safety Code, Sec. 611.002, 611.004
Mental Health Peace Officer
Page 70 of 97
June 2008
Unit Goal: 7.0. Gain an understanding of mental health referrals/resources in the
student’s community.
Our nation’s system of jails and prisons has now become the largest facility for persons
with mental illness. Police have become the “first responder” to persons in crisis
situations. Judges, law enforcement personnel, and mental health experts struggle with
trying to find a solution to the increasing numbers passing through the legal system. The
Mental Health Association of Texas states that “deinstitutionalization without adequate
community supports (such as supported housing and employment) contributes to an
increase of people with mental illness in prisons.” There is an overrepresentation of
people in our prison system. While only 3% of violent behavior is attributable to mental
disorder, an estimated 16% of prisoners have mental illness, and 50% of the young
people under the Texas Youth Commission have a mental disorder. TYC further reports
that in 2002, 21% of its institutional population were on psychotherapeutic medications..
There has been a rise in the number of persons with a mental illness or a co-occurring
disorders who are appearing before the court system. Many alternatives to the
“traditional” court model are being initiated, including drug courts, mental health courts,
domestic violence courts, and community courts. Programs such as the Jail Diversion
Program are also being implemented in many states, including Texas (see HB 2292).
These courts/programs have been implemented to address the underlying issues that
brought the consumer to court in the first place, their mental illness The aim is to link
consumers to community-based services.
Persons with mental illnesses are reportedly arrested at a disproportionately higher rate
than other individuals (Lamb and Weinberger, 1998). Over 11 million adults are booked
each year into U.S. jails (Steadman et al., 1999).
7.1. Investigate possible referral/treatment challenges in your community.
Once you have the individual in crisis de-escalated, you may need to take them to a
facility for emergency psychiatric evaluation. Depending on the resources in your area,
this may be a time-consuming process primarily due to a lack of available services. Be
aware of this potential challenge, but don’t let it detract you from your goal of responding
professionally and appropriately to the situation.
In addition to the previously mentioned resource challenges, there is also an impasse with
the willingness of mental health providers to participate in criminal justice initiated
programs. Just like society’s stigmas and discriminations against mentally ill individuals,
the mental health system often discriminates against people who have been arrested or
incarcerated, due to stereotypical concerns about criminal behavior and their lack of
experience working with this population.
Mental Health Peace Officer
Page 71 of 97
June 2008
The quality and availability of mental health programs vary depending on the respective
community’s mindset. Budgeting restraints also enter into the picture as a serious
concern. Even within a community, services available depend on timing, resources, and
program eligibility criteria. Too often, community mental health resources are in short
supply. High costs of prescription drugs and formulary limitations also make it
impossible for an indigent person to get access to needed medications.
Instructor Note:
Discuss student’s experiences in their home communities.
7.2. Discuss the players and strategies needed to coordinate a quality community
mental health program
Responses by law enforcement alone cannot effectively reduce or solve mental health
concerns. Consider who else in your community could share in these responsibilities and
be better suited for the issues at hand.
Framework of Responsibilities
Criminal
Justice
Rehabilitation
Prevention
Crosstraining
Crime
management
Mental
Health
Treatment
Rehabilitation
Prevention
Crosstraining
Disease
management
Community Family
Rehabilitation
Housing
Income
Support
Job training
Advocacy
Social
Services
Care
Representa- Rehabilitation
Rehabilitation tion
Housing
Housing
Protection
Income
Income
CrossSupport
Support
training
Job-training
Crosstraining
Ways to assess community resources might include:
1. Working with the mental health community
Neither the mental health community nor the law enforcement community can manage
the mental health issue alone. It requires both areas of expertise and resources to
successfully fulfill the mental health consumer needs.
Instructor Notes: Police departments should take the lead in building collaboration and
partnerships among these groups to enhance incident response, coordination, and
prevention. Why? Discuss.
A guest speaker as a Mental Health representative to answer student questions would be
of benefit in this section of the curriculum.
2. Working with emergency hospitals
Mental Health Peace Officer
Page 72 of 97
June 2008
Police departments should meet with area hospital administrators periodically to define
expectations and develop quality protocol for solutions to mental health issues.
Instructor Notes: It should be the responsibility of police commanders and specialists to
work these matters out in advance, so that the patrol officers with people in crisis at 2am
do not have to argue and debate with hospital staff. Discuss and problem-solve.
3. Training generalist police officers (Discuss generalized)
Although this is vital to program success it is no single solution and should not be
regarded as such. The aim of training is to:
 Enhance officers understanding of mental health
 Increase the knowledge of available community resources and dispositional
alternatives,
 Develop some basic crisis communication skills
Instructor Notes: Evaluated programs have indicated that training as suggested above
can succeed in improving understanding and knowledge, but it is much more difficult to
change the law enforcement officers existing attitudes and behaviors. More strategies are
needed for this fundamental change to take place. Discuss statement.
4. Providing more information to patrol officers
Patrol officers can benefit the most from two specific types of information:
 Information about clinics, shelter, and mental health services available in
community (referral sources)
 Availability of information concerning community members with a history of
mental illness. (consumer identification)
Instructor Note:
How is this accomplished in the State of Texas? Discuss any bills associated with this
topic, re. DPS access to confidential mental health information for identification
purposes.
5. Using less-lethal weapons
Resolution of most mental health issues can occur through maintaining a calm demeanor,
using good verbal and nonverbal communication, utilization of appropriate tactics, and
additional alternatives short of deadly force.
Instructor Note: Locate area examples to illustrate this statement. Discuss with class.
6. Deploying specialized police officers
Selection of a cadre of specialized officers can be utilized in all crisis situations that
occur with individuals with a mental illness. Evidence indicates that the CIT team model
has worked effectively in many departmental environments nation-wide. Teams report
response time is within an average of 10 minutes and handle approximately 95% of the
calls. (Memphis CIT model)
Mental Health Peace Officer
Page 73 of 97
June 2008
Instructor Note:
Limitations of the Memphis CIT model include:
 All officers will need to be trained in smaller agencies
 Experience in handling Mental Health situations in small communities is limited
due to small population numbers
 Collaboration between law enforcement and mental health agencies may be non
existent due to lack of resources
 CIT model is not as effective in smaller jurisdictions, but is more effective than
many other alternatives
7. Initiating assisted outpatient treatment:
Due to the deinstitutionalization of the mentally ill in the United States, many persons
with serious mental health issues are living in the community and on the streets. For a
variety of reasons many of these individuals fail to be consistent in taking their prescribed
medications. In most states however, if an individual is under court jurisdiction, they may
be mandated to some sort of treatment.
Instructor Note: Studies completed in New York and North Carolina demonstrate that
when mechanisms are in place to encourage adherence to prescribed treatment,
problems are reduced.
8. Establishing crisis response sites:
Several departments have created specific facilities where police can transport people
experiencing a mental health crisis. This is an alternative to an emergency room situation
or jail. What makes these alternatives different, even though they are generally located in
hospitals, is they are a central drop off point where the individual can receive not only
mental health assessment but substance abuse services. These facilities are also known
for their no-refusal policies. By utilizing these type of sites it reportedly reduces officer
frustration and gives an alternative to housing at the jails via arresting procedures.
Instructor Note:
Discuss availability of these sites in student’s area. If one is available in class locale, a
class visit would be beneficial.
9. Establishing jail-based diversion:
When an individual with a mental illness is arrested for a minor crime or disorderly
conduct, diverting them to mental health services after booking is a jail-based diversion.
Programs like this benefit the jail by removing these individuals who require alternative
services and placing them where they can be treated by qualified mental health
professionals while remaining under direst law enforcement supervision.
Instructor Note:
Except when people with mental illness commit a serious crime, arresting and housing
them in the jail environment is reportedly unproductive. People with mental illness often
get worse while incarcerated at the same time interfering with proper jail/prison
operation. Victimization and suicide are all too common in these cases.
Mental Health Peace Officer
Page 74 of 97
June 2008
Instructor Note: EX: The jails serving New York, Los Angeles, and Chicago each hold
more persons with mental illness per day than any hospital in the United States.
10. Establishing mental health courts:
Most prosecutors and judges are unfamiliar with mental health issues, as well as
appropriate referral sources in the community. Applying special protocols would also
assist immensely. By utilizing a mental health court option, judges can hear all mental
health cases and have ready access to mental health professionals. They understand the
specific needs of these defendants and can thus make better decisions for adjudication
and sentencing tailored to the individual. This also better protects the community.
Instructor Note:
According to a collaborative survey conducted by NAMI, the GAINS Center, and the
Council on State Governments, at least 94 communities across the U.S. have established
mental health courts as of June 2004.
Portland state researcher Heidi Hendricks followed 368 people who were diverted to the
Clark County Mental Health Court from the traditional court system. Her results are as
follows:
 In one year after being diverted, those in the group were arrested a total of 713
times
 One year after completing the mental health court program, 199 of the group
(54%) had no new arrests
 For that same period, there were only 178 arrests for the entire group - a 75%
reduction at a time when there was no longer court oversight
 Probation violations dropped by 62%
 The percentage of those in the group with three or more arrests dropped from
26% to 3% (an 88% decline)
Eighteen months after introducing a mental health court, Oklahoma County officials
assert that the county saved as much as $15,000 per year by putting an offender in
treatment instead of jail.
Instructor Note:
If there is a mental health court in class area, a visit to observe or a mental health court
judge as a guest speaker would be a good experiental tool.
11. Protecting repeat crime victims:
Previous victimization is generally the best predictor of future victimization. Identifying
these repeat victims can assist in identifying “causes” of victimization that could lead to
solutions that could possibly eliminate future problems.
Instructor Note: EX: If a person with a mental illness is a repeat victim, an abusive
caregiver might be identified, or the consumer may bet habitually victimizing others.
Mental Health Peace Officer
Page 75 of 97
June 2008
12. Ignoring the needs of people with mental illness:
Due to many factors including frustrated police officers, the response to persons with
mental illness is often just ignoring disruptive behavior, and hoping no one complains.
Doing nothing, however understandable, leaves the situation unresolved and is seen as
poor policing by the community.
Instructor Note:
Discuss. Has this ever happened to you?
7.2.1. Define a partnership and its relevance in community and law enforcement
collaboration
Definition of a partnership
An arrangement between two or more parties who have agreed to work cooperatively
toward shared objectives in which there is: shared authority and respect, joint investment
of resources, shared liability or risk taking, and ideally, mutual benefits
Definition of collaboration:
A system that integrates the resources and delivery of appropriate Mental Health care
services through processes or techniques used by different entities in order to control or
influence: the quality, accessibility, utilization, costs and prices, or outcomes of social
services provided to a defined population.
Components of a collaborative effort:
 Stakeholders interest in the collaboration
 Trusting relationship
 Shared vision and common goals
 Expertise
 Teamwork strategies
 Open communication
 Motivated partners
 Means to implement/sustain the collaboration
 An action plan
Why is collaboration important?
 Consumers/family seeking help in both systems
 Full range of services improves quality of treatment
 Mental Health professional: feels less overwhelmed due to safety factors
 Law Enforcement feels more confident in managing this population
 Focus on consumer needs
 Ensures highest standards
 Maximizes the value of funds
 Breaks down barriers
Mental Health Peace Officer
Page 76 of 97
June 2008
“The criminal justice and mental health worlds are very different. We come from
different traditions, we speak different languages, and to some degree have different
values, expectations, and goals. Furthermore, few of us expected or desired to work in
both the criminal justice and mental health worlds, and few of us have been trained or
educated to understand the other world.”
Instructor Note:
Discuss the following chart depicting mental health and law enforcement professionals
differing points of view.
Work with:
Institutions
Emphasis
Deals with…
Uses…
Deals with…
Views…
Views…
Both look at others worlds
as…
Feels…
Law Enforcement
Perpetrators, Defendants
and Offenders
Jails and Prisons: pressure
to reduce utilization and
rely on community
resources
Public Safety
Behavior
Authoritarian and
Adversarial
Recidivism where common
and not unexpected
Mental Health individuals
as odd
Mental Health as fuzzy
thinkers, too process
oriented and take too long
to reach conclusion.
Everything gray.
Chaotic and impossible to
understand with
indecipherable jargon used
to confuse other
Not appreciated for the
pressure they are under to
deal with the endless stream
of perpetrators, defendants
and victims
Mental Health
Patients, Clients or
consumers
Hospitals: pressure to
reduce utilization and rely
on community resources
Least Restrictive
Alternative
Illness
Team Approach, not sure
who is in charge
Chronic illnesses where
relapse is common
Law Enforcement
individuals as autocratic
Law Enforcement as world
of rigid thinkers, make
decisions too quickly, see
everything in black and
white, fail to appreciate
debilitating nature of MI.
Chaotic and impossible to
understand indecipherable
jargon used to confuse other
Unappreciated for pressure
it is under to care for
endless stream of patients it
is asked to serve
These biases make it almost impossible to work together. But do they have more in
common then they think? Both care about the people they serve, want to live more
productive and happier lives, to protect the world, fear the newspaper headlines involving
on of their “customers”.
Mental Health Peace Officer
Page 77 of 97
June 2008
First step to successful collaboration: desire to work together on solutions. “…the
fundamental and realistic commonalities shared by the mental health and criminal justice
systems could potentially span the boundaries artificially erected between the two
systems.”
Result:
For maximum success, people who become increasingly comfortable working with the
other systems must emerge. Perhaps the most difficult challenge is a willingness to give
up some degree of control to allow for real collaboration. These collaborations require
time, commitment, and risk. Without such efforts we will continue to inappropriately
incarcerate people who suffer from serious mental illness and need effective treatment,
not punishment.
Ideally people with mental disorders would come to the attention of the criminal justice
system with the same frequency as the general population with the same demographic
characteristics. People with mental illness who commit crimes with criminal intent and
unrelated to symptomatic mental illness should be held accountable for their actions as
would anyone else. While mental illness does not preclude criminal behavior, there is no
reason to believe people with MI are more prone to commit criminal acts. People with MI
should not be arrested simply because of their mental disorder. Nor should such people
be detained in jails or prisons longer than others because of their illness.
There is a direct link between inadequate mental health services and the growing number
of mentally ill who are incarcerated…CJ/MH consensus project
It has been long recognized that Law Enforcement collaborative agreements with Mental
Health agencies is the key approach in dealing with the national Mental Health service
crisis.
Instructor Note:
Discuss this statement and list on whiteboard or flip chart the statements reasoning.
Utilize this as a class review exercise.
7.3. List the mental health facilities in your area that can be utilized as a resource
when encountering a subject/suspect you identify as having possible mental heath
issues.
Instructor Note: Use MHMR or comparable entity for state referral sources per region.
Have students compile a referral list and research appropriate contact numbers.
7.4. Discuss the State of Texas Jail Diversion Ideal
Instructor Note: The following information is taken from the ‘Public Safety Net’
publication titled "Psychiatric Crisis System-Jail Diversion." Refer to it for expanded
information.
Mental Health Peace Officer
Page 78 of 97
June 2008
Elements of the Texas Jail Diversion Ideal:
 Education and training of law enforcement personnel and the courts
 The development and utilization of crisis intervention teams (CIT)
 Development of a centralized location for mental health assessment, without,
arrest for individuals with non-violent criminal conduct
 Development of holding facilities providing structured treatment in lieu of arrest
 Development of linking and referral services
 Development of timely and effective screening process
 Development of required community support
 Development of an identified method for addressing housing and needed support
services
Instructor Note:
H.B. 2292 states that “the department shall require each local mental health authority to
incorporate jail diversion strategies into the authority’s disease management practices
for managing adults with schizophrenia and bi-polar disorder to reduce the involvement
of those clients with the criminal justice system.”
How does this House Bill assist the law enforcement community?
There are two types of jail diversion: pre-booking and post-booking
Pre-booking diversion occurs at first contact with law enforcement, prior to any formal
charges. Most communities that use this system have specialized training for their
officers and a 24-hour crisis center with a no-refusal policy. The Crisis Intervention Team
process is an example of this approach.
Post-booking diversion is the most used program. This process is to identify and divert
consumers after they have been booked. A plan is then created for implementation upon
consumers release from jail.
Jail Diversion Concept Facts:
 Nationally, nearly half of the inmates in prison with a mental illness were
incarcerated for committing a non-violent offense
 Some 150,000 former patients of TDMHMR now find themselves caught up in
the criminal justice system, mainly because there was no other place for them to
go
 Calls for police services in which mental illness is a factor make up between 7%
and 10% of all police contacts, and continue to pose significant operational
problems for the police
 National analyses has demonstrated that diverted clients have significantly lower
criminal justice costs than non-diverted clients
Jail Diversion Benefits:
 Decriminalization of persons with mental illness
Mental Health Peace Officer
Page 79 of 97
June 2008







The problem of overrepresentation of people with mental illness in the criminal
justice system is addressed
Reduced hospitalization
Increased public safety
Reduction of inappropriate incarceration of persons with mental illness
Length of stay in jails shortened in lieu of increased access to treatment
Violence and victimization is reduced
Costs incurred by taxpayers when a person with a mental illness is arrested,
incarcerated, and/or hospitalized are addressed
Instructor Note: Refer to www.solutionfortexas.info/id257.html for an example of a jail
diversion model. See also the PowerPoint presentation titled “Bexar County Jail
Diversion-Bridging the Gaps in Mental Health” and “Diversion Components of Harris
County” By Monalisa Jiles, M.Ed., NCC, LPC, LNFT, SWA.
Instructor Note: Refer to “The Scope of Mental Illness and Criminal Justice Involvement
in Texas” By Dave Wanser, Ph.D., Deputy Commissioner for Behavioral and Community
Health Services. See also “ Austin Travis County Mental Health and Mental Retardation
Center, Executive Summary for Jail Diversion Initiative,” prepared by Susan Stone and
Associates, in conjunction with ATCMHMR Jail Diversion Workgroup and Community
Forum Participants.
Mental Health Peace Officer
Page 80 of 97
June 2008
8.0. Unit Goal: Understanding program evaluation in demonstrating/measuring
success.
It is critical to do at least a basic program evaluation. Measuring program effectiveness
can assist in determining how successful your program responses are to your area. It will
also evaluate any changes or adaptations/modifications that might be appropriate. Look at
trends for the total agency. In order to obtain an effective measurement, effective
documentation is necessary.
Start by identifying performance measures based on your program goals. These measures
should consider quantitative data on key aspects of program operation, as well as
qualitative data on the officers and community member’s perceptions of the program. It
will be helpful to gather documented baseline data prior to program implementation for
later comparisons with new program information, as well as to compare the performance
of CIT trained officers to non-CIT trained officers. Sharing statistics with other agencies
for comparison evaluation may also be helpful.
The quantitative data collected should focus on questions most critical to the programs
success in achieving its goals. Such information would include:
 The number of injuries and deaths to officers and citizens
 Officer response time
 Number of incidents to which specially trained officers responded
 The number of repeat calls for service
 Officers disposition decisions (linking services)
 Time required and method used for custodial transfer
Data should also be used to refine program operations as needed, as well as review
individual case outcomes and determine if follow-up by MH professional is warranted.
Methods for compiling qualitative data could be from officer surveys, both from
specialized officers and others. In this manner chief administrative officers can better
assess the programs usefulness to the entire department and be informed in order to
address any concerns.
Three other types of useful data could include:
Quantity Data:
The number of training events, officers trained and CIT officers on duty.
Process Data:
The number of:
 Identified CIT calls
 CIT calls handled by CIT officers
 Post intervention follow-up
 Response time
 Time delays in admission
Mental Health Peace Officer
Page 81 of 97
June 2008
Outcome data:
 Service links
 Civil protective custody
 Use of force incidents
 Injuries
 Jail diversion
 Criminal bookings
Collecting Data
 Ensure mechanisms are in place to capture data consistent with the process
and outcome measures identified
o Agree upon common definitions of MI and the characteristics of the
general population
o Capitalize on existing management information systems to facilitate
data collection and analysis
o Solicit comments and opinions from staff, crime victims, family
members, and program participants
o Establish procedures early in the process to share information that will
facilitate the data collection of people served by both the criminal
justice system and mental health systems
Departments also should focus on sustaining internal support for the program, such as
offering refresher training to help officers refine their skills and expand their knowledge
base, incentives and other organizational support for serving in the program should also
be considered.
Instructor Note: Example Exercise
Exercise I: The following are questions that could be adapted to data collection. Utilize
these questions for a group exercise. Have students place these questions in appropriate
categories per data collection information explained in above section.
What is your desirable outcome?
 Jail diversion-decreased cost
 Decreased use of force and injuries-improved risk management
 Increased links-improved treatment and decreased crisis events
 Improved general public and consumer/officer relations
 Arrest and use of force has decreased
 Underserved consumers are identified by officers and provided with care
 Patient violence and use of restraints in the ER has decreased
 Officers are better trained and educated in verbal de-escalation techniques
 Officers’ injuries during crisis events have declined
 Officer recognition and appreciation by the community has increased
 Less victimless crime arrests
 Decrease in liability for health care issues in the jail
Mental Health Peace Officer
Page 82 of 97
June 2008












Overall cost savings
Reduced victimization of people with mental illness
Reduced repeat victimization of people with mental illness
Reduced total calls for service involving people with a mental illness
Reduced calls for service at “hot spots” (do not include group homes etc.)
Reduced amount of police time consumed by calls involving people with mental
illness
Reduced total calls for each type of situation involving people with a mental
illness
Reduced arrests of people with a mental illness (assuming alternatives to
incarceration are available)
Increased referrals of people with mental illness to community-based services
Reduced injuries to police officers caused by people with mental illness
Increased “customer” satisfaction-post incident satisfaction of complaints,
victims, and offenders
Increased “expert” satisfaction-high ratings of police effectiveness by mental
health and legal professionals.
Instructor Note: Exercise II
Discuss this list with class and have students add to the list as appropriate.
Measuring and evaluating Outcomes:
 Establish process measures to assess how well the program activities have
been implemented
o Number of people served
o Units of service
o Timeliness of service
o Public safety
o Quality of life
o Cost
o Quality of Service
Mental Health Peace Officer
Page 83 of 97
June 2008
In conclusion:
This curriculum takes into account that law enforcement officers play different roles
in their encounters with persons with a mental illness. As first responders, they may
provide immediate aid. As law enforcement enforcers, they may encounter victims,
witnesses, or suspects who have a mental illness. As service personnel, they may help
people obtain psychiatric attention or other needed services. Helping people with
mental illnesses and their families obtain the services of other government agencies,
mental health organizations, hospitals, clinics, and shelter care facilities has become a
critical role for police.
It is important to dispel commonly held misconceptions about people who have
mental illnesses. This training is based on the following working assumptions.
1. Mental illness is not a crime.
2. Most people with mental illnesses are fully functioning community members.
3. There is no correlation between mental illness and a persons participation in
crime.
4. Involvement in infractions (traffic violations, loitering, disorderly conduct) may
be a manifestation of a persons mental illness or failure to receive treatment for
the illness, rather than a result of intentional wrongdoing.
5. Some people with mental illnesses may be more vulnerable to crime, abuse or
injury than the general population.
6. Mental illness is a continuum- highly functional to highly debilitating.
Mental Health Peace Officer
Page 84 of 97
June 2008
Mental Health Peace Officer
Page 85 of 97
June 2008
INTERNET RESOURCES
Resource
Internet Address
Mental Health - Government Sites
Americans With Disabilities Act Home Page
Arizona Peace Officer and Training Board
Houston Police Department
Ohio Criminal Justice Coordinating Center of Excellence
San Antonio Police Department
TDCJ (note: link to TCOMI home page)
Texas Dept. of Mental Health and Mental Retardation
www.usdoj.gov/crt/ada
azpost.state.az.us
houstontx.gov
www.neoucom.edu
www.sanantonio.gov/sapd
www.tdcj.state.tx.us
www.mhmr.state.tx.us
Organizations
Alzheimer’s Association (note: “Safe Return” program)
American Association on Mental Retardation
American Psychiatric Association
Americans with Disabilities Act Information Line
The ARC of the United States
Capacity For Justice (note: publications)
Conflict Research Consortium
Criminal Justice / Mental Health Consensus Project
Crisis Hotline (Houston)
Internat’l Assoc. of Forensic Mental Health Services
International Critical Incident Stress Foundation, Inc.
Mental Health Association of Texas
National Alliance For the Mentally Ill
National Alliance For the Mentally Ill – Texas Chapter
National Depressive and Manic-Depressive Association
National Down Syndrome Congress
National GAINS Center
National Institute of Mental Health
Public Citizen’s Health Research Group
Substance Abuse and Mental Health Services Assoc.
TAPA Center for Jail Diversion
The Arc
Treatment Advocacy Center
Mental Health Peace Officer
Page 86 of 97
www.alz.org
www.aamr.org
www.psych.org
www.ada.gov.
www.thearc.org
capacityforjustice.com
www.colorado.edu
consensusproject.org
www.crisishotline.org
www.iafmhs.org
www.icisf.org
www.mhatexas.org
www.nami.org
texas.nami.org
www.ndmda.org
www.ndsccenter.org
www.gainsctr.com
www.nimh.nih.gov
www.citizen.org
alt.samhsa.gov
www.tapacenter.org
www.theard.org
www.psychlaws.org
June 2008
Mental Health Peace Officer
Page 87 of 97
June 2008
References
First Response to Victims of Crime. (2007). Office for Victims of Crime. U.S.
Department of Justice, Office of Justice Programs.
Cordner, Gary. Problem-Oriented Guides for Police, No. 40. (2006). U.S. Department of
Justice, Office of Community Oriented Policing Services. Retrieved January
2008 from www.cops.usdoj.gov.
The Police Response To people With Mental Illnesses. Trainers Guide and Model Policy.
(2007). Police Executive Research Forum.
Criminal Justice/Mental Health Consensus project Report. (2007). Council of State
Governments. Retrieved January 2008 from www.consensusproject.org.
James, R. and Gilliland, B. Crisis Intervention Strategies. (2005). Thomson Books,
United States.
Police Response to People with Mental Illnesses (1997). Police Executive Research
Forum. US Department of Justice.
Woody, M. The Art of De-escalation.
Munetz, M. and Teller, J. The Challenges of Cross-Disciplinary Collaborations: Bridging
the Mental Health and Criminal Justice Systems. (2004).
Law Enforcement Interactions with Persons with Mental Illness. (2003). Texas Law
Enforcement Management and Administrative Statistics program, TELEMASP
Bullitan.
Tobar, H. When Jail is a Mental Institution. (1991). Los Angeles Times.
Criminal Justice Weekly. Ohio Department of Public Safety, Office of Criminal Justice
Services. Retrieved April 2008 from www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf.
NAMI Ohio Offers Training for Jails and Court Personnel to Communities in Ohio.
(2002). NAMI-Ohio. Retreived March 2008.
Mental Health Peace Officer
Page 88 of 97
June 2008
Mental Health Definitions
Definitions are taken from
MayoClinic.com in cooperation with
Mayo Foundation for Medical Education and Research
Mental health definitions
addiction. Dependence on a substance, such as alcohol or drugs. It's usually
characterized by impaired control over and preoccupation with the use of the substance,
as well as continued use of the substance despite adverse consequences.
adjustment disorder. A psychological response to a stressor that results in emotions or
behaviors that are greater than would be expected by the stressor or that cause significant
impairment in functioning effectively.
adrenaline. A naturally occurring hormone that increases heart rate and blood pressure
and affects other body functions. Also called epinephrine.
adverse reaction. Negative or unwanted effect caused by a medication. Also called side
effect.
affect (AF-ekt). Current, observable state of feeling or emotion, such as sadness, anger or
elation.
affective disorder. A type of mental disorder that primarily affects mood and interferes
with the ability to function, such as major depressive disorder and bipolar disorder. Also
called mood disorder.
alcoholism. A disease in which there's a craving for alcohol and continued drinking
despite alcohol-related problems, such as legal trouble. It's also characterized by impaired
control over your drinking, a physical dependence on alcohol, and alcohol tolerance —
requiring increasing amounts of alcohol to feel its effects..
anhedonia (an-he-DOE-ne-uh). Reduced or complete inability to feel pleasure from
activities that usually produce happiness.
antidepressants. Medications that improve or relieve symptoms of depression or other
psychiatric disorders by affecting brain chemistry.
antipsychotics. Medications used to treat psychotic illnesses. Also known as neuroleptic
medications.
Mental Health Peace Officer
Page 89 of 97
June 2008
antisocial personality disorder. A mental disorder in which there's a disregard for and
violation of the rights of others. Behavioral patterns include deceitfulness, lack of
conformity to social norms, and reckless disregard for the safety of others or the self.
anxiety. An unpleasant emotional and physical state of overwhelming apprehension and
fear.
anxiety disorders. A group of conditions marked by persistent, extreme or pathological
anxiety. They may be manifested by disturbances in mood or emotions, as well as by
physiological symptoms, such as elevated blood pressure, rapid breathing and rapid heart
rate.
bipolar disorder. A type of mood disorder that causes periods of low and high moods —
depression and mania. Also called manic depressive disorder.
borderline personality disorder. A type of personality disorder characterized by
instability in the perception of self and others, unstable personal relationships, intense
anger, feelings of emptiness and fears of abandonment.
chemical imbalance. Having too much or too little of such brain neurotransmitters as
serotonin or dopamine, which may play a role in depression and other mental illnesses.
chronic. A term used to describe long-lasting diseases or conditions.
cognitive. Pertaining to the mental process of thought, including perception, reasoning,
intuition and memory.
cognitive disorders. A set of disorders consisting of significant impairment of thinking
(cognition) or memory that represents a marked deterioration from a previous level of
functioning.
crisis. A sudden intensification of symptoms that results in marked inability to function
and possibly raising the risk of harm to others or the person in crisis because of
overwhelming emotion, disturbed thinking or risky behavior.
delirium. A state of mental confusion, usually temporary, that is sometimes characterized
by disordered speech and often accompanied by hallucinations.
delusions. A firmly held belief with no basis in reality – that is, clinging to a belief even
when the evidence shows that it’s false.
dementia. Persistent, worsening mental deterioration with prominent effects on memory
and behavior arising from organic causes, such as Alzheimer's disease or the cumulative
effects of small strokes.
Mental Health Peace Officer
Page 90 of 97
June 2008
depression. A mood state characterized by extreme sadness, hopelessness, lack of selfworth and discouragement. Also called clinical depression, major depression and major
depressive disorder.
dual diagnosis. Having a substance abuse problem along with another psychiatric
disorder.
dyskinesia (dis-kih-NE-zhuh). Involuntary muscle activity causing distorted movement
of the lips, tongue, neck, arms or trunk, sometimes as a side effect of certain medications.
euphoria. A feeling of elation or exceptional well-being.
factitious disorders. Disorders in which a person fabricates illness or injury in order to
gain attention, such as Munchausen syndrome.
flashback. An involuntary recurrence, often repeatedly, of a feeling, memory or
experience from the past.
generalized anxiety disorder (GAD). A mental disorder that causes extreme worry and
tension for six months or more.
hallucination. A sensory perception with no basis in reality. It may be seen, heard, felt,
or smelled.
histrionic personality disorder. A disorder in which your behavior is characterized by
being overly dramatic, excessively sensitive to the approval of others, excessively
concerned with your appearance, and by an exaggerated level of intimacy in
relationships.
mania. A mood disorder characterized by an intense feeling of elation or irritability and
rapidly changing moods (mood lability), often accompanied by increased activity, rapid
speech or distractibility.
manic depression. See bipolar disorder.
mental disorder. A general term for a wide range of disorders that disrupt thinking,
feeling, moods and behaviors, causing a varying degree of impaired functioning in daily
life, and believed in many instances to be related to brain dysfunction. Also called mental
illness.
mental health. A general term for a state of emotional and psychological well-being that
allows you to function in society and meet the demands of everyday life. Or, the term for
your overall emotional and psychological state.
mixed episode. A period in which symptoms of both mania and depression occur at the
same time or rapidly alternate with one another. Also called mixed type.
Mental Health Peace Officer
Page 91 of 97
June 2008
mood. An experience of emotion that can influence your perception of the world.
mood disorder. See affective disorder.
narcissistic personality disorder. A disorder in which you have an inflated sense of
your own importance, an extreme preoccupation with yourself, an inability to empathize
with others, and a propensity for attention-seeking behavior.
narcosis. A state of stupor, often induced by drugs or other agents.
neurotransmitters. Naturally occurring chemicals in the brain that act as messengers
between nerve cells, affecting brain function and mood. Those associated with depression
include serotonin, norepinephrine and dopamine.
not otherwise specified (NOS). A designation used as a broad diagnostic category when
a person's condition doesn't precisely fit specific psychiatric categories or when a doctor
doesn't have enough information for a specific diagnosis.
obsession. A recurrent unwanted thought, image or impulse that's distressing and comes
to mind despite efforts to suppress or ignore it.
obsessive-compulsive disorder. An anxiety disorder characterized by intense, unwanted
and distressing recurrent thoughts (obsessions) and repeated behaviors (compulsions) that
are difficult to control.
panic attack. A period of sudden, intense apprehension, fearfulness or terror often
associated with impending doom and accompanied by physiological symptoms, such as
shortness of breath, palpitations, pounding heart or chest discomfort.
panic disorder. An anxiety disorder characterized by chronic unexpected episodes of
potentially disabling intense fear or anxiety, often accompanied by physical symptoms,
such as rapid heartbeat and dizziness.
paranoia. A mental disorder, or an element of several other mental illnesses,
characterized by suspicion, delusions of persecution and jealousy.
passive aggression. Indirectly and unassertively expressing aggression toward others,
masking resentment or hostility.
personality. Enduring patterns of perceiving, relating to and thinking about yourself and
the environment.
personality disorder. A broad term for a cluster of 10 different conditions marked by a
variety of maladaptive personality traits and behaviors, such as paranoia, narcissism or
sociopathy.
Mental Health Peace Officer
Page 92 of 97
June 2008
pharmacotherapy. Treatment of disease with prescription medications.
phobia. A persistent, excessive fear of a specific object, activity or situation, resulting in
a compelling desire to avoid that which provokes it.
post-traumatic stress disorder (PTSD). A type of anxiety disorder characterized by
intrusive memories of a traumatic or highly stressful event, often characterized by
nightmares, flashbacks, depression, hopelessness and loss of interest in activities.
psychosis. A mental disturbance characterized by a loss of contact with reality. Delusions
and hallucinations are often present.
psychotic. Having delusions or hallucinations that cause disorganized thinking, unusual
behaviors and loss of touch with reality.
relapse. Reappearance of disease signs and symptoms after apparent recovery.
remission. Abatement of signs and symptoms.
repression. Unwilled banishment of disturbing wishes, thoughts or experiences from
conscious awareness.
schizophrenia. A severe, chronic mental disorder caused by brain dysfunction, resulting
in hallucinations, delusions, distorted thinking and other disturbances.
seasonal affective disorder (SAD). A cyclical type of depression related to a change in
season. It usually develops with the onset of winter, when sunlight is limited, and fades
with spring.
self-esteem. Opinion of yourself.
serotonin (ser-oh-TOE-nin). A type of neurotransmitter believed to influence mood.
side effect. See adverse reaction.
social anxiety disorder. A type of anxiety disorder that causes significant anxiety and
discomfort related to a fear of being embarrassed, judged, humiliated or scorned by
others in social or performance situations. Also called social phobia.
split personality. A non-medical term sometimes used to describe dissociative identity
disorder (formerly called multiple personality disorder) or, incorrectly, schizophrenia.
See also dissociative identity disorder.
stigma. Negative attitudes about or toward those with mental illness, usually stemming
from fear and misunderstanding, and resulting in disgrace, embarrassment or humiliation
for those with mental illness.
Mental Health Peace Officer
Page 93 of 97
June 2008
suicidal ideation. Thoughts of suicide or a desire to end your life.
suicide. Intentionally taking your own life.
symptom. A subjective manifestation of a condition that's reported by the individual and
not observable by others, such as sadness. See also sign.
synapse. The junction between two nerve cells (neurons).
syndrome. A collection of signs and symptoms that characterize an ailment.
tardive dyskinesia (TAHR-div dis-kih-NE-zhuh). An abnormal, involuntary movement
disorder of the facial area, trunk or extremities, sometimes resulting from treatment with
certain antipsychotic medications.
thought disorder. Mental disorders characterized by an impaired perception of reality,
such as schizophrenia.
Tourette's syndrome. An inherited neurological disorder that causes repeated
involuntary movements (tics) and uncontrollable vocal sounds or speech.
withdrawal. The process of stopping a drug.
By Mayo Clinic staff
MH00039
March 10, 2005
© 1998-2005 Mayo Foundation for Medical Education and Research (MFMER). All
rights reserved. A single copy of these materials may be reprinted for noncommercial
personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "Mayo Clinic Health
Information," "Reliable information for a healthier life" and the triple-shield Mayo logo
are trademarks of Mayo Foundation for Medical Education and Research.
Mental Health Peace Officer
Page 94 of 97
June 2008
APPENDIX
Mental Health Peace Officer
Page 95 of 97
June 2008
Activity
Auditory Hallucinations
Purpose: To expose students to the fear, frustration, and confusion of auditory
hallucinations.
Materials: Two copies of “Voices” script
Time: About 20 minutes including discussion following activity.
Roles: a person with schizophrenia, a law enforcement officer and 2 voices.
Instructions: Have Voices stand on each side of person with schizophrenia and the law
enforcement officer stand in front of them. The voices should begin reading the script
into the ears of the consumer while the officer role-plays a session of questioning.
Upon completion of 2-3 minutes have class discuss exercise.
Voice 1 Script:
You jerk!
Stupid!
Everyone knows it
They’re all looking at you
They know you are stupid
They are all laughing at you
You’re ugly
Hide your face
Run away
You’re no good
You lazy, good for nothing
Get a job you bum
Do something
Don’t listen to them
This is boring
Hurt yourself
You deserve it
You’re useless
No one cares
Voice 2 Script
Save these people
They’re devils
They must be persecuted
God works through you
You can save the world
You are Jesus Christ, son of God
Mental Health Peace Officer
Page 96 of 97
June 2008
Cleanse yourself
Save the world
Dirty! Dirty!
Take your clothes off
Purify yourself
Go naked in the presence of God
Naughty! Naughty!
You’re tired
Get out of here
Go to sleep
They’re staring with evil eyes
Run away
Hit them now
Hit! Hit!
Before they hurt you
Mental Health Peace Officer
Page 97 of 97
June 2008