PIIMIC
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Police Intervention - Intervention Tips
Focus on safety, manage immediate danger
Get briefing from others (family, friends in attendance) about safety risks such as history of violence or suicide. Ask them calmly: "are there any drugs, alcohol or weapons involved or any in the house? I need to know for my own safety: where are the weapons?" Separate the subject from location of any weapon.
Ask family/friends about any known diagnosis and recent behaviour. Explain you need to talk to the subject one-on-one and they should not be in the same room unless arranged. Create a calm space around you and the subject. Create an escape route for yourself if needed. Do not get yourself into a position where you can be cornered. Do not assess the subject in a kitchen (too many potential weapons). Do not let subject walk away from you, alone, to another room. Do not crowd an agitated, aggressive, or paranoid subject. Back off. Give him time and space. Allow several extra feet of personal space between yourself and any psychotic subject.
If the subject is armed or has access to a weapon, or is aggressive and threatening violence, and the situation is escalating, call for support. Watch the subject's hands, keep them in sight. Use a calming tone of voice but establish that you are in control: "No. Back off and put it down. You're not taking control. That's our job. We've got what we need, including weapons … So let's calm down, and everything will be all right. Nobody needs to get hurt. Now this is the way it's going to be... " (Also see control lines.)
Establishing friendly communication in a non-aggressive situation
Introduce yourself by name. Include your first name. Use the subject's name. Make normal eye contact but do not stare. Your manner should be calm and reassuring. Try for rational conversation, try to work together. Don't be in a rush. Wait for answers.
- "Take it easy. Tell me what's troubling you, what's the issue?"
- "If you're afraid of anything right now, it's OK to be scared. But don't be afraid of me. I am here to help you or to resolve the issue."
- "We know you're not at your best right now. What kind of problem are you having? How can I help? What do you need?"
Conversation may be difficult but patience will help. Speak slowly and briefly. Wait for answers as the subject may be having trouble sorting out incoming messages. If subject is unable to respond coherently to such questions, medical attention may well be needed urgently. Do not talk about either subject or family in their combined presence as though either party was not there. (Also see opening lines.)
Try for sit-down conversation
If subject is calming down and seems stable, it's OK to let him pace for a minute or two but don't let agitation build up. When ready, ask a supportive question like: "Are you mostly OK now?" Arrange to sit beside the subject or make a corner if possible (this is less confrontational than face-to-face). Ask simple questions one at a time like "What's been troubling you? What kind of problem are you experiencing? Is it your medication? Is something causing stress? Has this happened to you before?" Wait and listen to answers. Make brief notes of the subject's major issues, e.g. grief, job setback, social or family difficulties, medication not working. There is no need to agree with subject's perspective or priorities, but do show empathy for what subject is experiencing: "it sounds like you are going through a lot of stress, it must be rough for you."
Managing subjects with a mental disorder who are obviously at risk
- If the subject's general behaviour is unsafe
Examples include: highly agitated, aggressive, anxious/panicky, unpredictable, out of touch with reality, incoherent, suicidal, etc. Medical attention is urgent. Intervene quickly and firmly, leading with behavioural evidence (reflect what you're seeing): "You seem to be very troubled and (angry, upset, anxious, suicidal etc). We need to bring you to medical attention right away, for your own safety and good health. Maybe all you need is a change of medication. OK, now let's get your medication, show me where it is." Follow the subject closely, take note of the medication and check the dosage. Ask subject about last dosage, when and how much. Secure it and make sure it goes to hospital with yourself or ambulance. "If your medication is not working well for you, you can tell the doctor about it."
If the subject is unable or unwilling to talk, sit down, offer to wait a minute and then try again. If subject still won't talk, "OK, you're still not speaking to me right now, I will have to go along with other information." Review collateral info from family/friends. "We're concerned about your health situation under the Mental Health Act. We're obliged to take you to hospital to be checked out by a doctor. If you want to go voluntarily, you can ride in the ambulance. Otherwise in the police car. Your family/ friends can follow and be in the waiting room. Have I explained everything clearly? What's your choice?"
- If the subject is argumentative and denies needing help
"You have certain rights, including the right to receive medical attention. We're concerned about your health situation and safety under the Mental Health Act. We're obliged to take you to the hospital, to be checked by a doctor. If you resist I will have to arrest you. Now let's go quietly to the hospital. Your family/ friends can follow and be in the waiting room."
- if the subject is getting more psychotic and frightened
Someone who is psychotic may be stressed and frightened by own symptoms and/or police. Be sympathetic about the subject's problems: "I can appreciate that these problems frighten you and upset you. They don't have to make you feel this way. Help is available and you can be feeling much better quite soon."
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Answering specific questions about medical treatment
This is a role for a psychiatric nurse or other health professional, not a proper role for police. "I can't answer specific questions about medical treatments. I'm not qualified to do that." Police can point out that education is available from support groups and through Mental Health Centers and hospitals. Typical education messages are that stress and mental disorders respond very well to medical treatment and guidance. Treatments are easy to take. When properly complied with, new medications are usually very effective at controlling symptoms with only minor side effects. Surgery is no longer used. Shock therapy has special permission protocols, is rarely used and only for severe depression when pills and counseling don't work. The new pills deal with certain brain chemicals, nudge them back into balance. We can all use a bit of rebalancing once in a while. Treatment plans also aim to improve life style through better nutrition, more exercise, better sleep, and less stress.
Non-obvious safety risks in psychosis
Police need to form an opinion of safety risk. A serious risk may be obvious from observed behaviour, actions and other physical circumstances; or it may be invisible: limited for the time being to mental condition and perhaps to the history of the case. Although not obvious, the subject's psychotic symptoms may still be likely to endanger: for example, the subject hears commanding voices and cannot resist their control of his actions. The subject may have a history of inappropriate, harmful behaviour. These circumstances pose a high safety risk. They illustrate that police need to probe for signs of unsafe psychosis, and collateral information. Non-obvious factors that are "...likely to endanger the safety..." of the subject or others can be grounds for police intervention.
(This does not mean police should try to form a diagnosis of a specific illness. Diagnostic work is for specialists only, because psychotic symptoms can vary and overlap. Also symptoms can have various sources like brain injury, drugs and alcohol, certain infections, dementia. Police should be cautious about using medical terms like "symptoms, diagnosis, psychosis," unless the subject uses them first.)
In probing for unsafe psychosis, see if the subject can remain focused on here and now. Test for contact with reality: "Do you know where you are? What day is it? What time?" Being badly out-of-touch with reality and in non-supportive circumstances is dangerous for the subject.
Ask the subject "what are you experiencing? Do some things appear strange or very different? Do you see or hear things that other people can't see or hear? Visions or other sensory distortions are signs of psychosis that can distract the subject into unsafe behaviour. "Do you hear voices?" If the subject hears voices: "Are they your usual voices? What are they saying? Is it disturbing or soothing? Are they putting you down? Do you feel safe about it? Can you turn your mind onto something more pleasant?" If the subject does not feel safe about the voices: "Do you feel you have to agree right now, or can you disagree with them?" Note: commanding and irresistible voices can place most subjects at high risk. Winston Churchill used to hear inner voices but he always argued with them. Possibly this improved or reflected his mastery of oratory and debate.
The bottom line of psychosis: "These thoughts you're having, or visions or voices you're hearing, do they make you feel dangerous, or unsafe, vulnerable or out of control? Do you want to harm or kill someone? Do you want to die? Are you suicidal? Do you have a plan?" Do not use "hurt yourself" as it may be confusing. Most patients do not want to suffer pain even if they do want to die.
No matter how negative the answers to these questions, police can help the subject into a more positive outlook: "Would you rather continue to feel like this, or would you let us help you out of it?" Listen carefully and make notes about other unsafe psychotic signs. While probing for safety risks and the need for treatment, police should also make reassuring comments to the subject: "We'll get you into safety and help. You'll be in the driver's seat again."
Get history of illness
Ask subject (& others): "Has this happened to you (or him/her) before? Have you been in hospital before? Where? Have you been using drugs or drinking alcohol? For how long? Who have you been seeing when you felt unwell?"
Get medical treatment information
"Who is your doctor now? Who else do you see when you're not feeling well?" Discuss and check medication. Ask if the subject is on medication or other treatment? For how long? Ask about compliance - and note the answer. "Are you taking the medication? Where do you keep it?" Secure it to accompany subject if transported to hospital. If an overdose or other serious medical problem is suspected, call EHS (ambulance) and if necessary ask EHS for first-aid advice.
Deal with Denial
Make note if you believe the subject is hiding symptoms and denying a mental illness. In such cases, subjects can appear quite normal for a brief time, but a few minutes of conversation may reveal signs of confused thinking, abnormal moods, disturbed emotions or strange behaviour. Also ask others. They called you there for a reason. Also see control lines in this topic.
Prioritize subject's safety and health
"When symptoms overwhelm you, it's your right to be safe, to be protected from possible harm, and to receive a doctor's attention. Do you want your family or friends to follow you to the hospital/doctors office?"
Be moderate in use of force/restraint
Use only to the extent needed. Consider the alternative of backing away from confrontation and letting the subject cool down. A subject with mental illness may be extremely sensitive to perceived aggressive threats and manhandling, posing the risk of a severe setback. Consider the available means-of-force options. If officer safety is involved, and a high degree of force is indicated, there are several non-lethal choices including the taser - a compact stun gun that is authorized for police in BC and has proven to be very effective in many situations, resulting in little or no long-term injury. People fear electric shock even when psychotic. Subjects tend to surrender very quickly when "painted" with the red dot of the built-in laser sight and asked if they want to experience 50,000 volts. Even if the subject is manic or intoxicated and feeling no pain, the taser is able to physically interrupt neuro-muscular control and drop the subject without lasting injury. In one such case, where a psychotic naked male on a rooftop defied police, officers sneaked up a ladder from the rear and dropped him with a taser. He cooperated with being handcuffed, and said (with less bravado), "Why didn't you tell me you were going to zap me? I would have given up right away."
Copyright
The name and contents of PIIMIC are copyright jointly by the Justice Institute of BC Police Academy and the author, Richard Dolman, except for the material in Legal Issues section B on Mentally Disordered Offenders (“MDO section”) which is copyright by Richard Dolman. All material except for the MDO section is available for free copying and downloading by others in Canada for not-for-profit educational uses in Canada, provided appropriate credit is given. Sales or other commercial uses of any of the contents of PIIMIC are strictly forbidden without written permission. Please contact
rdolman@telus.net
on copyright inquiries.
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