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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