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AJP Author Spotlight: Law Enforcement, Psychiatry, and People Living With Mental Illness

March 9, 2020


The American Journal of Psychiatry – Collaboration
to Reduce Tragedy and Improve Communities: Law enforcement, Psychiatry, and People Living
with Mental Illness – AJP-16-08-0985.R2 Transcript Video 1: Case #1
Nils A. Rosenbaum (NAR): Hi I’m Nils Rosenbaum. I’m a psychiatrist. I work with the Albuquerque Police Department. Matthew A. Tinney (MAT): And I’m Matthew Tinney. I’m a detective at the Albuquerque Police
Department. I wanted to tell you guys about a case in
which we wouldn’t able to have successfully complete without the use of a psychiatrist. This was a woman that came to our attention
from multiple calls for service, for police calls for service or emergency calls for service. She made a lot of complaints that seemed to
be about people breaking into her home, replacing furniture, stealing furniture or objects or
moving things around. And you know as law enforcement, gets lots
of calls about break ins but this one was unique because she talked about things being
replaced or she started believing that they were shapeshifters or spirits that were able
to go in and out of the walls; and we attempted with field officers, so uniform patrol to
make contact to reduce these calls for service and get her help. We just kept hitting the wall because we didn’t
have enough to take her in to the hospital at these times or anything with criminal justice,
it’s not against law to call the police and one time she went to a substation and luckily
enough we knew that Dr. Rosenbaum was available. And so we did an intervention there. NAR: The detective and I, Matt Tinney, spent
about 45 minutes interviewing her. She clearly had some delusions about spirits
coming through the walls. So we knew that she had psychotic symptoms
but we didn’t know why nor did we find any clear dangerousness until we really investigated
and it turned out that we asked her about safety and how she was going to keep herself
safe from these spirits and what did she say, Matt? MAT: Well at that point she clearly demonstrated
that she was going to keep herself safe by showing that she got a gun by doing this (finger
gun motion with hands) and saying that any time that she heard of a spirit or what she
believed to be a spirit coming through the house, as she would then proceed to just shoot
her firearm in that direction hoping to hit the spirit and sure enough we went out into
the parking lot and she had just purchased a firearm that day, it was sitting in her
car. NAR: So we took the gun, Matt took the gun
into custody and we got her to the hospital. She got admitted to a geriatric psychiatric
ward and she got much better and it was a good communication between law enforcement
and medical providers to make sure everything was evaluated properly and treated properly
so we were pleased with that outcome. MAT: It was a nice way that hopefully we prevented
a future tragedy with someone that had a firearm that really just needed medical intervention. But law enforcement side we just did not know
how to get there. So it was great having a doctor available
for that. NAR: Well thank you Matt. It was great to have you there too. Excellent. Thanks. Video 2: Case #2
Nils A. Rosenbaum (NAR): Hi, my name is Nils Rosenbaum. I’m a psychiatrist. I work with the Albuquerque Police Department. Matthew A. Tinney (MAT): And I’m Matthew Tinney. I’m a detective with the Albuquerque Police
Department. NAR: Matt and I work together at the police
department and we try to help with cases of people who come in contact with police and
try to keep them safe and get them into services. There was one case where a patient’s mom was
calling the police constantly worried about the safety of their son and he was living
in motels in bad neighborhoods and Matt and I visited him frequently. I mean we must have gone at least 15 times. Generally, he would slam the door in our face
and yell an expletive but eventually… MAT: Show some hand gestures… NAR: (chuckle) Eventually he did talk to us
and I was able to talk to him about medicine and he was somewhat receptive but it took
at least four or five more visits before he just one day invited us in and we chatted
with him for a long time. We were, from that point on, we were able
to get him into services on Medicaid. On a subsequent visit, we coordinated with
someone from Medicaid. We got him on medication. We found him an outside doctor and within
months his apartment went from completely trashed to clean. He shaved his beard. His mom was very pleased. It was a nice story, especially for someone
in law enforcement because you don’t often see the results of your hard work. MAT: And he enrolled back in school. I think one of the unique things about it
was frequent calls or service in law enforcement are typically handled in a criminal justice
setting. So how do you get this person to quit calling
again or get this person off the streets and having doctor to kind of guide our investigation
and to say this looks like a serious mental illness. Let’s try rapport building and we can effectively
reduce the calls for service by engaging this person in services and get them into a long
time treatment. And for me this is the first time I saw someone
living with severe mental illness. We always see the negative in law enforcement
but to see them in treatment and doing better! NAR: Yeah, it’s nice. MAT: I mean, he went from living on the streets
to living in and out of hotels to going back to school; it was amazing. NAR: Yeah, and he’s doing well. So that was exactly what Matt was saying,
it was a nice example of collaboration working out well for the community. Thank you Video 3: Case #3
Nils A. Rosenbaum (NAR): Hi, my name is Nils Rosenbaum. I’m a psychiatrist. I work with the Albuquerque Police Department. Matthew A. Tinney (MAT): And I’m Matthew Tinney. I’m a detective with the Albuquerque Police
Department. NAR: We wanted to tell you quickly about a
case that highlights the work that we do together. There was a man who was prone to psychosis
and at times he would get violent to the point that a SWAT team had to be called out to his
house. He was very strong and a large guy and kind
of impervious to pain. They had to use a lot of tactics to get him
out. He was slightly wounded. One of the officers was wounded and he did
get to the hospital. Subsequently, we as a team, with the detectives
and I, were working more closely with him. So the idea would be to see him before he
got very bad or look for the first signs of his decompensation and intervene at that point. So we were working closely with the University
who was his outpatient provider and with the field of the police. Together we met him and were able to get him
into services earlier by establishing rapport while he was doing well. MAT: This is a very different model than what’s
in traditional law enforcement. With this particular gentleman, there had
been actually multiple SWAT activations and so this requires a SWAT team, a lot of heavy
equipment, things like that. He had a history of fighting with law enforcement
so he would get arrested a lot from felony charges, it would injure a lot of law enforcement. So the typical model in law enforcement is
very reactive. You wait until someone reaches that point
of an extreme or a crisis and it generates a call for service. Then you go out and handle it immediately. And so, the approach that Doc brought to it
is let’s do a different approach. It might seem foreign but let’s intervene
in the beginning. Let’s, you know, we have a history of this
person going to continuously have these big calls for service and also fight. Ever since doing this earlier intervention,
be it in the criminal justice system, in jail itself, or prior, we’ve actually been able
to reduce, we haven’t had another SWAT activation and we have reduced any time that this gentleman
has fought with law enforcement. In fact, the last time he had interaction
law enforcement was because he was actually helping someone out, get them to the hospital,
which was nice. So he turned around and changed his civic
duties. NAR: Yeah. It’s amazing and it really is about making
that human connection early and connecting them with the proper services at the proper
time. So we were pleased. Thank you. Video 4: CIT Model
Nils A. Rosenbaum (NAR): Hi, I’m Nils Rosenbaum. I’m a psychiatrist. I work with the Albuquerque Police Department. Matthew A. Tinney (MAT): And I’m Matthew Tinney. I’m a detective with the Albuquerque Police
Department. I want to talk about the Crisis Intervention
Team Model, also referred to as CIT. You can replicate this in any community and
here in Albuquerque the model that we use starts off with collaboration. We include collaboration in all aspects of
law enforcement when it comes to the response of behavioral health. So we’ll use the local university and the
advocacy groups, local providers all together. This transitions to our training which is
a big part of this. Training isn’t the whole program but we do
believe that we need to raise the expectations of our officers and those we are hand-in-hand
working with. And so this also goes to providers. We do train with providers, with medical students,
with cadets in the law enforcement academy, and with senior officers going over responses,
didactics on mental health issues, you know, decreasing the stigmatization of mental illness
and law enforcement and providers together as a big group together on this one. The other big aspect of it is a coordinated
response. So we actually have full time detectives that
are purely responsible for responding to calls that are related to behavioral health, doing
follow up, to build this rapport up, to better influence decisions that someone in crisis
might be making. A big aspect of that is very unique that we
actually have a full time psychiatrist and so we’re able to use him to help guide some
of our decisions, which are outside of the traditional criminal justice mindset. NAR: Matt, if you were in a smaller agency
and they wanted to start a program, a CIT program, what would you suggest would be a
good start? MAT: I’d say the first thing is it’s all collaboration. I think you should reach out to whatever you
have in your local area. If you have a provider, reach out to your
provider. If you have a local college or university,
reach out to some of those professors or advocacy groups, like the National Alliance of Mental
Illness or any group that corresponds with someone living with a behavioral health condition. NAR: I agree. I think collaboration is the most important
aspect of the entire program and it constantly renews the program and keeps it up to date
and makes it effective. Without collaboration, you really have people
working in vacuums and nothing gets done properly. So I agree. What about having a coordinator? MAT: I do think that it’s very important to
have a full time person dedicated to this. That’s where a lot of agencies have difficulty
with manpower or given resources. But if you truly want to make effective change
in your community it’s nice to have a police department or whatever law enforcement agencies
in that area to dedicate that resource for that one person to be there and be that contact
liaison for the officers that are encountering this, family members, providers, everything
to coordinate this collaboration because it’s not easy. It takes time and it takes a lot of work. NAR: I agree 100 percent. I think the main thing is that CIT is not
just about training, although training is very important. Collaboration and then the actual responses
are essential to have a program that functions properly. I think it can be started in any agency no
matter the size. As long as you have one or two people who
are interested in the program and willing to make phone calls to mental health providers
or to police officers and start a collaboration. Video 5: Successful Collaboration
Mauricio Tohen (MT): Hi, I’m Mauricio Tohen. I’m Chair of the Department of Psychiatry
and Behavioral Sciences at the University of New Mexico. Matthew A Tinney (MAT): I’m Matthew Tinney. I’m a detective with the Albuquerque Police
Department. Nils A. Rosenbaum (NAR): Hi, I’m Nils Rosenbaum. I’m a psychiatrist. I work with the Albuquerque Police Department. MT: Today we want to talk about the importance
of collaboration between departments of Psychiatry, behavioral care providers and law enforcement. This is the approach that we’ve taken in Albuquerque. First, is in terms of patient care. We very much see law enforcement as part of
a treatment team. What do I mean by that? Well many times individuals who develop mental
illness, or who already have a mental illness and have an episode, the first contact that
they have is with law enforcement, it’s not with providers. Many patients don’t come directly to the hospital. They just become ill while they’re in the
streets and they could get into trouble, they could be victimized. We very much believe in patient centered care. That means that we go where the patients are. And certainly law enforcement is where patients
are. So I want to share some of the experiences
that we’ve had working together including some of the challenges. I would say that the key thing is collaboration,
not only in terms of patient care, I think also in terms of training and talking to each
other. The more we know about each other’s needs
and challenges, the more we can work together because we have the same goal, which is to
optimize the outcomes of patients with mental illness. -Any experiences that we have? NAR: Yeah, we have really done a lot more
training recently and over the last few years. One of the things that sometimes is difficult
for field officers is they’ll take somebody to the hospital who says, that may be suicidal
or psychotic and then they drop them off and all they find out is that they were let out
quickly or they don’t know anything. And so obviously confidentiality is extremely
important. But one of the ways to help officers feel
like they’re making a difference, which they are ,is to train them and to train, we have
the Director of the Psychiatric Emergency Services from UNM (University of New Mexico)
come teach. If you would like to talk about that. MAT: That’s right. I think one of the big misconceptions is in
law enforcement we assume everyone falls under the same guidelines as we do. So whatever law gives us the right as officers
to take someone in for treatment against their will, we assume that that’s the same law that
gets them admitted. So we assume that everyone is getting admitted
to the hospital. And sometimes it’s the terminology that we
use doesn’t translate back and forth. So there’s just been this miscommunication
historically between law enforcement and providers. So now actually having providers there, we’re
humanizing it and making it so that the officers feel free to ask questions. We can translate back and forth the misunderstandings
we both have; such as if someone’s asking “why did you guys bring them to the hospital
and not to jail?” That’s a big one we get when it’s not against
the law in this state to make threats against someone. And so we can’t just take people to jail because
they’re threatening people. MT: And you both make a very important point,
which is the importance of talking to each other. Like the case you mentioned, that an officer
brings a patient to the Psychiatric Emergency Services and then the patient is discharged
and the officer is not informed. So Nils brought that to my attention, we talked
among the faculty and what’s important is to make sure that the officers understand
the issue of privacy and that we just can’t let law enforcement know once a patient is
discharged because of confidentiality. Once faculty is aware of it and talked to
officers, I think there is a much better understanding and again that leads to better outcomes. NAR: Yeah, the outcomes are improved when
the communication is better and there’s less sort of lack of knowledge and sort of resentment. Once you realize and talk to them and everybody
is a person that you can ask questions and get good responses, it just makes things so
much better. Most importantly for that community and the
patients. MT: Actually, the other thing is that, when
cadets start their training, one of the first things they do is they come to the Psychiatric
Emergency Services; they familiarize themselves with the staff, with the place and I think
that has led to great outcomes. I would say that our goal is the same. Both for law enforcement and for behavioral
care providers, which is to optimize the outcome of patients with mental illness. The way to do it is to work together and to
understand each other’s challenges. I recommend this to any department of psychiatry
who is looking after , well – who is community oriented. I’m sure that APD (Albuquerque Police Department)
would have the same recommendation. MAT: I would say yes. NAR: Oh, absolutely, absolutely. It’s been an incredible collaboration.

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