Psychiatric Crisis and Law Enforcement

I attended the National CIT (Crisis Intervention Training) in Memphis, Tennessee from Monday, August 27 to Thursday, August 30, 2007. I was scheduled to do a presentation on "Promoting Cultural Change with Words" and I was a bit leery of going because I was unsure of how to present a workshop to law enforcement officers. Based upon my limited personal experience, I was only familiar with law enforcement as ultimate authority figures. The uniforms are designed to be threatening and intimidating. Like the military (where many officers were originally trained) most of the attendees wore crew cut hair. It was pretty easy to identify law enforcement officers just by the "look."

Formation of CIT (from sources on the web)

CIT stands for ≥Crisis Intervention Team,≤ and refers to a collaborative effort between law enforcement and the mental health community to help law enforcement officers handle incidents involving "mentally ill" people. The first CIT program began in Memphis, Tennessee. In 1987, 27 year-old Joseph Dewayne Robinson (a Black man) was shot and killed during an incident with the Memphis Police Department. All of the officers involved in the incident were Caucasian. Several White police shooting a Black man outraged the community. (In addition it was known by police and the mental health system that Mr. Robinson "cut on himself." I've never heard of a "cutter" who wasn't a survivor of serious abuse, neglect or trauma. That seems to always get overlooked. Instead, victims tend to get revictimized.)

Following this fatal shooting, in 1988, the Memphis Police Department joined in partnership with the Memphis Chapter of the Alliance on Mental Illness (AMI) a "family member" organization, local mental health providers, and two local universities (the University of Memphis and the University of Tennessee) in organizing, training, and implementing a specialized unit. This unique and creative alliance was established for the purpose of developing a more intelligent, understandable, and safe approach to mental health crisis events. This community effort was the genesis of the Memphis Police Departmentπs Crisis Intervention Team. That's great but something's missingä NOTHING ABOUT US WITHOUT US! Where were (are) the mental health recipients/former recipients in the design and implementation of the program? (See model curriculum following)

I also have some other issues with the CIT model that was based on the Memphis model. The Memphis model is based on officers volunteering for the training. Officers who are selected in part because they volunteer generally means that you get officers who are compassionate. However – what happens when a CIT trained officer is not available? What then? For small communities (e.g., rural) sending officers to a 40-hour training (based on the Memphis CIT model) is a large burden. Not only does it take one of their officers off the street – but then they may need to back fill the officer's position or borrow law enforcement officers from a neighboring community.

The Growth of CIT

CIT has now spread to most major cities and over 2300 law enforcement agencies around the country. This spread is being spearheaded by NAMI. For the most part, we (mental health recipients/former recipients) are excluded from planning and all but minimal participation in the actual trainings.

Training for CIT is done by local NAMI (National Alliance on Mental Illness – a primarily "family member" organization) and the local mental health community. Mostly, this means that for 40 hours of training, consumers/survivors/current and former mental patients are pretty much left out. Yes, we get to do anywhere from 2 – 4 hours of the training but that's generally less than 10%. We need to be included in both the design and implementation (training) of this program. Our voice should be the primary one in this program. Any training involving women should involve a majority of women. Any training involving people of color should involve a majority of people of color. Any training involving people with mobility impairments should involve many people in wheelchairs. Any training involving current and former mental health service recipients should involve us in a primary way.

Medical Model

Another problem with CIT training is that the bulk of the training is done by people who are almost totally "medical model" in their belief system. Adherents to the medical model believe that a disabled person's problems are caused by the fact of his or her disability and thus the question is whether or not the disability can be alleviated. Advocates of the disability-rights model, on the other hand, believe that a person with a disability is limited more by society's prejudices than by the practical difficulties that may be created by the disability. Under this model, the salient issue is how to create conditions that will allow people to realize their potential. The disability rights model is preferred by advocates within the mental health community.

CIT training allegedly trains law enforcement officers to assess "mental illness." When they feel they are interacting with someone they consider might be "mentally ill" they then practice techniques designed to connect with the person and convince them to go with the officers to some sort of "treatment." Police officers aren't qualified to "assess" based upon 40 hours of training. Frequently, not even psychiatrists are able to assess to the extent that even two of them will agree. Assessment is a judgment call and I am very uncomfortable with law enforcement passing judgment on people in this manner. Also, I don't believe in "mental illness" and the fact that officers will be judging and then directing people to "treatment" for alleged "mental illness" is a dangerous use of implied authority as coercion.

Other branches of medicine don't engage in force through coercion and intimidation in order to force compliance with medication.

There is potential for several dangerous scenario's. Law enforcement could be used to sweep people into forced or coerced "treatment" who are really trying to cope with social issues such as poverty, homelessness and social oppression. Law enforcement through CIT training develops relationships with "family members" and then when a family member is distressed, they can call and report someone who is allegedly "mentally ill" and have that person taken into the custody of the mental illness "treatment" system. This enables the ultra right-wing conservative NAMI (heavily influenced by the psycho-pharmaceutical industry) to have law enforcement (quasi-military) as their "enFORCEment" branch.

NAMI supports the use of TASER's and other "less than lethal force" choices such as beanbag guns however, many have already died. "Less than lethal force" is a concept that may work when applied to some mythical "norm" but it doesn't work with people who are taking psychiatric medications. Often, there are so-called side-effects from these medications that result in problems with heart, blood pressure, blood sugar, weight and other physical issues. If a person is already hypertensive it increases the chances that a jolt from a TASER might be fatal.

The fanatical NAMI even supplies most of the "consumers" for CIT training by using those who are already pretty co-opted and who serve as NAMI poster children. They are trained to recite the medical model mantra about the efficacy of psychiatric drugs without even blinking. I've nothing against psychiatric drugs but I worry about the recent report that states that those of us who have been psychiatrically labeled live a shortened life span of an average of 25 years less than those who haven't received psychiatric "treatment." I worry about the connection to those drugs that cause all sorts of debilitating effects from weight gain to diabetes to sudden death. NAMI feels that anything that "controls" us and makes us less of an inconvenience to the families is a good thing and the drugs do that very well. NAMI and the medical model mental health system feel that a quiet client who causes no community disturbance is deemed "improved" no matter how miserable or incapacitated the person may feel as a result of the "treatment." This is how they are training law enforcement: force people to take drugs, drugs and more drugs and if they won't take them, make them.

I wasn't scared when I went to this conference. I was a bit unsure of how to approach law enforcement officers since I felt that it would not sit well with their "authority figure" persona to have me try to act as if they had something to learn. I did okay. I presented on how to help change from a culture of weapons to a culture of words. Some attendees seemed almost puzzled because I wasn't typical medical model. I spoke of discrimination and prejudice. I spoke of how the system oppresses mental patients and teaches them learned dependency. A few seemed to understand. Then I went out and interacted with others at the rest of the conference and I got more and more scared. I overheard NAMI fanatics and I saw NAMI folks "suck up" to the cops and I saw the cops "suck up" to NAMI folks and in the midst of this mutual admiration society, I started to get panicky. I recalled another fanatic group in the 1930's and 1940's who used the muscle of a heavily armed law enforcement branch to impose their will. I started to "flashback" to scenes of goose-stepping authorities imposing oppression on those they deemed different and not "pure" – people sort of like those of us who have been labeled as having a brain disease caused by an impure mind due to a chemical imbalance.

I watched the disingenuous smiles of the NAMI folks and I realized that I'd come face to face with the enemy. Those of us who are part of the movement for human rights in opposition to psychiatric oppression need to beware because, unbeknownst to most of us, NAMI is literally building an paramilitary army out of law enforcement that will be the enFORCEment arm of involuntary treatment. Be afraid, be very afraid!

"Adults with serious mental illness treated in public systems die about 25 years earlier than Americans overall, a gap that's widened since the early '90s when major mental disorders cut life spans by 10 to 15 years."

Report from NASMHPD (National Association of State Mental Health Program Directors), May 7, 2007

The World Health Organization (WHO) found that recovery from schizophrenia is at least 50% higher in emerging (third-world) countries that practice far less åWestern medicineπ and there are almost no psychiatric services.

Two studies by the World Health Organization (WHO), one in 1979 and the second in 1992, compared the recovery rate, mostly from schizophrenia, in developing countries with the recovery rate in industrialized countries. In 1979, WHO had about 1800 cases validated by Western diagnostic criteria in developing counties matched with controls from industrialized countries, and they found that the recovery rate was roughly twice as high in the developing countries compared with the industrialized.[1] They were so surprised by this that they said, "Well, this must be a big mistake." So they repeated the study in 1992, and they got the same results.[2]

[1] World Health Organization. Schizophrenia: WHO study shows that patients fare better in developing countries. WHO Chron. 1979;33:428.

[2] Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1-97.

Perhaps less invasive 'treatments' should be emphasized. Perhaps mental health courts should consider that they might be sentencing people to a death sentence of a shortened life span. When police with CIT training take someone into "treatment" perhaps they should realize they may be causing a shortened life.

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CRISIS INTERVENTION TEAM (CIT) TRAINING PROGRAM

Curriculum/Schedule

Monday

8:00 AM Welcome/Registration

8:30 AM CIT Program Overview

9:00 AM Signs and Symptoms of Mental Illness (#1)

10:00 AM Schizophrenia (#2)

11:00 AM Mood Disorders (#3)

12:00 PM Lunch

1:00 PM Personality Disorders (#4)

2:00 PM Understanding and Preventing Suicide (#5)

3:00 PM Child and Adolescent Intervention (#6)

4:00 PM Treatments of Psychiatric Illnesses (#7)

5:00 PM Class Discussion

Tuesday

8:00 AM Post-Traumatic Stress Disorder/Veteran Consumer Interviews (#8)

10:00 AM Site Visit @ Local State Psychiatric Hospital (#9)

12:00 PM (Note: Site visit will include a working lunch.)

2:00 PM Site Visit @ Local Emergency Receiving Facility (#10)

5:00 PM Class Discussion

Wednesday

8:00 AM Addictive Diseases (#11)

9:00 AM Co-Occurring Disorders (#12)

10:00 AM Developmental Disabilities (#13)

11:00 AM Alzheimer's Disease (#14)

12:00 PM Lunch

1:00 PM De-Escalation Techniques Part 1 (#15)

5:00 PM Class Discussion

Thursday

8:00 AM Consumer Perspectives (#16)

9:00 AM Family Perspective (#17)

10:00 AM De-Escalation Techniques Part 2 (#15)

12:00 PM Lunch

1:00 PM De-Escalation Techniques Part 2 (#15)

2:00 PM Cultural Sensitivity (#18)

3:00 PM Legal Issues and Mental Health Law (#19)

5:00 PM Class Discussion

Friday

8:00 AM Mental Health/Community Resources (#20)

9:00 AM De-Escalation Techniques Part 3 (#15)

12:00 PM Lunch

1:00 PM Review of CIT Principles

2:00 PM POST Written Examination/Course Evaluation

3:00 PM Graduation (Dress Attire/Uniform)

5:00 PM Class Adjournment

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November 2007

Well, I just completed a week of attending the local CIT training in Ashland, Ohio. It was pretty awful and I just wanted to let you know why.

First, it was heavily dominated and coordinated by NAMI. I get very tired of listening to family members whine. They complain about how difficult it is to live with someone with a "mental illness" but they never think about how difficult it might be to actually be the person with lived experience. I can't imagine family members of people in wheelchairs or any other disability whining in this same way. It's akin to men whining about how difficult it is to live with women (even though women live in a male dominated society) or white folks whining about how difficult it is to live with black folks (even though people of color live in a white dominated society).

Second, the total focus for the first three or four days was to force people to get "treatment" because (it is presumed) they are usually "off their meds." It seemed the message was that people can do fine if they take their meds but when they don't comply then they flip out and go crazy and the cops get called. NAMI wants the cops to take people to "treatment" rather than jail. NAMI wants the cops to take people to the hospital where they can be forced to take meds. NAMI wants the cops to take people into the emergency assessment units so that the people can be assessed for what meds they need to take. It was like a broken record. There was no room in the curriculum for "recovery" or any other message of hope. The message was that the only "hope" is to get people to take their meds.

Third, locally (and I imagine it happens this way elsewhere) they brought in "experts" on the topics. A local university Ph.D. talked about "borderlines" and I'll bet he'd never actually met a person with that diagnosis outside of his books. The same with schizophrenia and bipolar and even trauma (PTSD). These experts were chosen by NAMI in the planning process for this CIT training. NAMI loves "experts." NAMI seems to not want to talk about recovery or anything else except the "illness" and I believe it seriously tainted the training. If I were organizing the training, I'd at least have a person with lived experience as an equal co-presenter for every module of the training.

An issue that I have with CIT programs is that they rely heavily on mental health professionals and talk a lot about different diagnoses and medication. I find that problematic for a number of reasons: a) Law enforcement officers are not mental health clinicians. Most of them don't want to be mental health clinicians; b) There are many reasons why people don't take medication – not all mental health crises are a result of stopping medication – this argument over simplifies – it also doesn't address trauma issues; c) Law enforcement officers need training on how to respond to people experiencing extreme emotional distress--just because someone has a vague understanding of "schizophrenia" doesn't mean that s/he is equipped with the necessary tools to help someone experiencing extreme emotional distress calm down and resolve the situation in a peaceful resolution; and d) Many CIT programs present mental health issues in a biological framework. Again this oversimplifies mental health issues that are influenced by a multitude of factors including a) social expectations, b) environment, c) stress, d) trauma, etc. It imposes a Western European worldview on what mental illness is – and doesn't allow for individuals to have their own view of their experiences.

Fourth, several times, local NAMI (from a couple of counties and on the state of Ohio NAMI Board) mentioned that NAMI supports the use of TASER's. They made these statements in support of using "less than lethal force." It's scary but the cops loved it and believe they are being supported by NAMI in their use of TASER's. This despite the fact that we know that people are dying from TASER use. In fact, people are more at risk because of the adverse effects of the psychiatric medications but no one mentions this distressing fact.

Finally, the last day and a half was some role play. The cops were to practice using words, not weapons. This was presented by cops and actors from a neighboring county that has done CIT several times. It's my understanding that originally CIT video taped a few people with lived experience for training purposes – but no longer actively engages people who use/have used mental health services in the training. Instead, they have moved towards having law enforcement officers whose family members have mental health issues talk about their experiences. Again, I feel there should be "Nothing About Us Without Us." I also think there is a cultural issue for law enforcement officers around including us in training: That is, they feel we lack credibility in their eyes. If we experience delusions, have visions, hear voices, are afraid – they are thinking that we aren't credible in the eyes of the court. In part, that is why they rely on expert witnesses (e.g., mental health professionals) so much. I don't agree with this belief – but it is one we must contend with and keep in mind as we interact with the law enforcement community. This belief also makes it difficult for people with disabilities – particularly psychiatric disabilities to be taken seriously when they report a crime or abuse.

On the positive side, I believe everyone can benefit from learning techniques of verbal deescalation. In fact, verbal deescalation techniques originated several decades ago in the service industry. Hotel and food service workers have had to deal with so many confrontive situations that they started trainings on verbal deescalation long before the police and NAMI co-opted it. The role plays weren't that bad. Again, I feel things might have been improved by using actual people who have lived experiences with distressing emotions rather than officers/actors. The verbal deescalation training was good but short.

Overall, I again left CIT with a queasy stomach and concerns that NAMI is training their own personal para-military force in order to force us to comply with a drug regimen. This is particularly scary in light of the fact that as the national average life span is increasing (now 78), our lifespan is continuing a downward spiral (now an average of 25 years less). The message of drugs, drugs, drugs is doing great harm. It's not only a message lacking in hope but it's a message that is a lie. It causes us to gain weight, suffer early and deadly diabetes and so many other adverse effects. I've even read where we might die early because we smoke but the fact is that we smoke to counter some of the adverse effects of the medications. It's a lose/lose situation for us.

As an alternative, I want to explain how we did things in Denver in 1985, three years before CIT. Back then, I was working as part of an intensive case management team. We met with police at every shift change (four times a day at "report"). Every car and every officer had our phone number. If they suspected that the person had mental health issues, they could call us and we'd respond immediately. The advantage was that the police didn't have to be trained in amateur assessment. We'd do the assessment on the scene and we had the authority to then release the police back to patrol. Everyone loved it! It saved time, money and much paperwork. Of hundreds of cases, only a couple ever needed the police and those were cases where it seemed the person was on PCP (angel dust) and demonstrating super human strength and dangerousness. In all other cases, we were able to deescalate the situation and either get the person home or on about their business or voluntarily in for help. Now however, CIT is being touted as the best and "only" training of it's kind. There are alternatives that may be better but they're not being considered or given a chance.