5 RESPONDING TO MENTAL ILLNESS LEARNING OUTCOMES Upon completion of this chapter, you should be able to: Identify techniques for intervening with mentally ill persons. . Outline the options available to police when responding to situations involving persons who may have a mental illness. . Identify and apply pertinent provisions of the Mental Health Act of Ontario. . Identify signs and symptoms of excited delirium and how to avoid positional asphyxia. 147150 PART II MENTAL ILLNESS AND SUICIDE If the individual is not exhibiting the more obvious psychotic symptom CHAPTERS RESPONDING TO MENTAL ILLNESS 151 Such as hallucinations and delusions, detecting mental illness may be moreoms "cult. Speaking with the person may assist in determining whether they have If the psychotic person becomes aggressive, it is in the best interests of mental disorder. The officer should ask themselves the following questions when all concerned to isolate and contain the person. The officer may contain the Arson by not allowing them to leave the immediate surroundings. Officers speaking with the person: In achieve this by restricting access to exits or by setting, artificial boundaries Is the person able to conduct a conversation, or are their speech and using other officers and having non-essential persons leave the area. If there is thought patterns disjointed and confused? Is the person able to focus "potential for violence, officers can more easily focus on the psychotic person "ithout having to deal with the safety of others. Containment and isolation on the question posed? . Is the person aware of their surroundings? Can they provide their limit the options of the aggressor, restrict access to potential weapons, and name and address, provide the date, or answer common-knowledge confine the person to a designated area. However, the subject may also react negatively to isolation and containment by becoming more aggressive, particu- questions? arly if the psychosis is accompanied by paranoia. If the subject exhibits such behaviour and the scene is safely contained, officers may consider the option of disengagement. INTERACTING WITH PSYCHOTIC PERSONS It is unlikely that non-mental-health professionals will be able to identify Police may be called by concerned family members or other persons when psychotic behaviour induced through means other than a mental illness. Within someone is experiencing a psychotic episode. Psychosis is most notably found the provisions of the MHA, an officer who has reasonable grounds to believe in persons with bipolar disorder or schizophrenia. However, officers should that the psychotic behaviour was caused by a mental illness is justified in ap- consider other possible causes of the behaviour when attempting to interact prehending the person if they display violent behaviours. Section 17 refers to with a subject in a state of psychosis. Psychotic episodes may be caused by med. behaviours caused by an apparent mental disorder. The use of the word "appar- ical conditions such as brain tumours, severe fevers, or epilepsy. Reactions to ently" in this section of the Act removes the requirement for police to prove that a specific mental illness is causing the identified behaviour. (See the sec- alcohol or other drugs, head injuries, or acute stress could also induce psychotic tion titled "Immediate Apprehension" for the full text of Section 17 later in this behaviour. Hallucinations and delusions are the most frequently encountered symptoms chapter.) of psychosis, although there are several others, including THE BRIEF MENTAL HEALTH extreme anxiety, fear, or panic for no apparent reason SCREENER-POLICE . withdrawal from family or friends The interRAI Brief Mental Health Screener-Police (BMHS) is a standardized . rapid mood swings (also a symptom of bipolar disorder) mental health form used by front-line officers for calls involving persons experi- . loss of ability to verbally interact encing mental health issues. It is based on the interRAI Mental Health Assessment . disordered, fragmented speech System, implemented by the Ontario Ministry of Health and Long-Term Care for use with patients admitted to an Ontario hospital for inpatient psychiatric care. . loss of logical reasoning The BMHS is designed to help officers determine if they should immediately . flat affect (lack of emotion) in responses apprehend a person exhibiting indicators of mental illness for psychiatric as- . agitation. sessment or refer them to future assistance by a physician or to the appropriate community or social agency. Effective verbal interaction with a psychotic person may be extremely When police apprehend a person for assessment, the BMHS provides a sys- difficult because of their loss of ability to reason or think logically. The of- tematic way for officers to articulate and document their reasons for apprehen ficer should try to listen to the person empathetically and respond in a calm, sion in standardized medical terms used in the province's hospitals. reassuring manner. The officer must also be aware of their proximity to The screening tool's 23 mental health indicators, identified by the responding situation. the person. Invading the psychotic person's personal space can escalate the officer, can be used by health care providers to determine how to best assist the person in difficulty.152 PARTII MENTAL ILLNESS AND SUICIDE CHAPTER 5 RESPONDING TO MENTAL ILLNESS 153 COMPONENTS OF THE BRIEF MENTAL HEALTH SCREENER-POLICY there The BMHS is not reproduced verbatim nor in its entirety. The following is a sampling of criteria from HAMILTON'S MOBILE CRISIS RAPID RESPONSE TEAM the BMHS and is intended for information purposes only. Do not attempt to apply components of the BMHS without proper training. if possible, background information pertaining to the person should be obtained. If safe to do so Forovember 2013, the Hamilton Police Service implemented the Mobile Crisis Rapid Response Team. it In Norogram of its kind in Canada, the program pairs a police officer with a mental health worker." team is dispatched to "in- progress" calls involving a person in crisis . officers will speak with the person, using de-escalation techniques if necessary. through observation and conversation, the officer obtains as much information as possible regard Ing the person's mental state. The information required is categorized into two general general types : Indicators aram has reduced the MHA apprehension rate from 66 percent to 25 percent. Source : Hamilton Police Service ( 2018 ) . of Disordered Thought and Indicators of Risk of Harm. Greater numeric rating is usually indicativecato greater risk. The item below is excerpted from the Indicators of Disordered Thought section of the screener, In addition to Mental State Indicators and Behaviours, this section of the screener assesses the degree on insight the individual has into their mental health problem(s) and their cognitive skills for daily decision RESPONSE OPTIONS making. The Indicators of Risk of Harm section of the screener examines such aspects of the situation as whether the individual has had police contact in the past 30 days, has been known to carry weapons or Regulation 3/99 of the Police Services Act, section 13(1)(8), requires police ser- exhibit signs of violence or self-harm. the conditions of their home environment, and whether they have rices to establish procedures on dealing with persons who are emotionally dis- furbed or who have a mental illness. Police officers will follow the procedures of been taking their medications. their respective police services . The following information identifies some possible response options for po- INDICATORS OF DISORDERED THOUGHT lice officers dealing with mentally disturbed persons. This section is to be used 1. Mental State Indicators and Behaviours for information purposes only. 0 0-Not present 0 1-Present but not exhibited in last 24 hours NO FURTHER POLICE ACTION 0 2- Exhibited in last 24 hours This may occur in situations where the reported behaviour is disturbing but not O Irritability - short tempered, easily upset dangerous, such as a person walking on the sidewalk calmly talking to imaginary O Hallucinations people. Such people appear to be mentally disturbed but do not pose a danger Command Hallucinations to themselves or the public and are able to care for themselves. The officer forms 0 Delusions the opinion that the person is not likely to pose any danger. Source: Copyright 2014-15 by interRAI (www.interRAI.org). Reprinted with permission of interRAI. All rights reserved. RELEASE TO FAMILY OR FRIENDS With this option, the officer is somewhat concerned about the ability of the subject to care for themselves. The person has not displayed any dangerous be- MOBILE CRISIS INTERVENTION TEAMS haviour , but their ability to interact effectively may be somewhat hindered. The Mobile crisis intervention teams usually consist of uniformed police officers person may show signs of confusion, such as not knowing where they are, or not knowing the time, date, year, etc. These signs could lead the officer to believe trained in mental health issues working with mental health workers. The team is used as a rapid response option for calls involving people with mental health that the person's ability to care for themselves is compromised but that they pose no immediate physical danger. Release to the person's family or friends may be issues. In some police services, the mental health worker does not accompany a viable option if the officer is able to obtain the information required to contact been addressed. uniformed officers, but may respond after any potential safety concerns have a family member. The goal of the intervention team is to de-escalate and stabilize the person's In this situation, the person may not be suffering from a mental illness but behaviour and make an onsite assessment of the person in crisis. may be suffering from a condition such as Alzheimer's disease. The person The team can also provide the person with onsite supportive counselling and may exhibit many of the same symptoms and behaviours as a person with a referral to the appropriate agency for assistance. mental illness, but not be suffering from a mental illness within the meaning of the MHA.154 PART II MENTAL ILLNESS AND SUICIDE CHAPTER 5 RESPONDING TO MENTAL ILLNESS 155 VOLUNTARY ADMITTANCE if a person is displaying indicators that lead the officer to suspect that a psych; atric assessment may be needed, but the person is not exhibiting behaviour that would indicate they are a danger to themselves or others or that they and Incapable of self-care, the officer could ask the person to voluntarily submit to , Psychiatric assessment. Officers may apply this option in situations where the do not believe that an immediate danger exists, but are unable to release tix person into the custody of family or friends. If the person agrees, they may ne transported to a medical facility to be examined by a physician. The physician will decide whether or not the person should have a psychiatric evaluation. Under section 12 of the MHA, the subject may agree and be admitted for evaluation as an informal or voluntary patient. ADMISSION OF INFORMAL OR VOLUNTARY PATIENTS: MENTAL HEALTH ACT, SECTION 12 12. Any person who is believed to be in need of the observation, care and treatment provided in a psychiatric facility may be admitted thereto as an in- formal or voluntary patient upon the recommendation of a physician. As a voluntary patient, the person may leave the psychiatric facility at any time, The justice will hear sworn information from the concerned parties and de- according to section 14 of the MHA. cide, based on the information presented, whether the subject should be brought INFORMAL OR VOLUNTARY PATIENT: MENTAL HEALTH to a physician to determine whether a psychiatric evaluation is necessary. The justice issues a Form 2, MHA, Order for Examination (see Appendix 5.2 ACT, SECTION 14 at the end of this chapter), authorizing police to apprehend the named person 14. Nothing in this Act authorizes a psychiatric facility to detain or to re- within seven days and bring them to a physician for assessment, as set out in strain an informal or voluntary patient. sections 16(1) and 16(3) of the MHA. There is a problem when the person refuses to be admitted and family or friends JUSTICE OF THE PEACE'S ORDER FOR PSYCHIATRIC are not available. With no other legal options available, the officer must uncondi- EXAMINATION: MENTAL HEALTH ACT, SECTION 16(1) tionally release the person. He or she should keep detailed notes of the interaction 16(1) Where information upon oath is brought before a justice of the peace that a person within the limits of the jurisdiction of the justice, ORDER FOR EXAMINATION ISSUED BY A JUSTICE ud worved (a) has threatened or attempted or is threatening or attempting to cause bodily harm to him- or herself; An order for examination may be applicable in instances of unconditional re- (b) has behaved or is behaving violently toward another person or has lease to family or friends. If the family or any person believes, on the basis of caused or is causing another person to fear bodily harm from him or her; or their observations, that as a result of a mental disorder, the person poses a danger (c) has shown or is showing a lack of competence to care for him- or to themselves or the public, or has caused or is causing a person to fear for their herself, safety, or is unable to care for themselves, the person may appear before a justice and in addition, based upon the information before him or her, the justice seeking an order for psychiatric evaluation. This order is used in situations where of the peace has reasonable cause to believe that the person is apparently the subject will not voluntarily submit to an evaluation by a physician and the suffering from mental disorder of a nature or quality that likely will result in, police have not formed reasonable grounds to believe that the person poses an (d) serious bodily harm to the person; immediate danger to, or is unable to care for, themselves. (e) serious bodily harm to another person; or AHMod to ( f ) serious physical impairment of the person , the justice of the peace may issue an order in the prescribed form for the exam- ination of the person by a physician .156 PARTII MENTAL ILLNESS AND SUICIDE AUTHORITY OF ORDER: MENTAL HEALTH ACT, IMMEDIATE APPREHENSION CHAPTERS RESPONDING TO MENTAL ILLNESS 157 SECTION 16(3) 10(3) An order under this section shall direct, and, for a period not to ciccod seven days from and including the day that it is made, is sufficient au. in some situations, the immediate apprehension of a mentally disturbed person thority for any police officer to whom it is addressed to take the person named ""necessary-for example, where they are suicidal or violent, The person may of described therein in custody forthwith to an appropriate place where he or he experiencing episodes of psychosis, as described earlier. Such persons may pose a risk to the safety of intervening officers. Refer to the previously discussed she may be detained for examination by a physician. guidelines for dealing with these occurrences. the examining physician will determine whether the person needs to havea Apprehending a person without prior judicial authorization is allowable only Psychiatric evaluation. If an evaluation is deemed necessary, the person may vol. when the safety of the individual or another person is, or is likely to be, in im- untarily submit to the evaluation or be required to submit to evaluation. Section minent jeopardy. Section 17 of the MHA allows for the immediate apprehension 15 of the MHA, below, authorizes the examining physician to order the person If the person only in circumstances where the officer does not have time to apply for judicial authorization through the provisions of section 16 of the MHA, as a to be evaluated at a psychiatric facility. result of the immediacy of the danger. The order is issued as a Form 1, MHA, Application by Physician for Psychiatric Assessment (see Appendix 5.1 at the end of this chapter). The order ACTION BY POLICE OFFICER: MENTAL HEALTH ACT , authorizes police to apprehend the named person within seven days and bring SECTION 17 them to a psychiatric facility for evaluation. 17. Where a police officer has reasonable and probable grounds to believe APPLICATION FOR PSYCHIATRIC ASSESSMENT: that a person is acting or has acted in a disorderly manner and has reasonable cause to believe that the person , MENTAL HEALTH ACT, SECTION 15(1) (a) has threatened or attempted or is threatening or attempting to cause 15(1) Where a physician examines a person and has reasonable cause to be- bodily harm to himself or herself; lieve that the person, (b) has behaved or is behaving violently towards another person or has (a) has threatened or attempted or is threatening or attempting to cause caused or is causing another person to fear bodily harm from him or her; or bodily harm to himself or herself; (c) has shown or is showing a lack of competence to care for himself or herself, (b) has behaved or is behaving violently towards another person or has and in addition the police officer is of the opinion that the person is apparently caused or is causing another person to fear bodily harm from him or her; or suffering from mental disorder of a nature or quality that likely will result in, (c) has shown or is showing a lack of competence to care for himself or (d) serious bodily harm to the person; herself, (e) serious bodily harm to another person; or and if in addition the physician is of the opinion that the person is apparently (f) serious physical impairment of the person, suffering from mental disorder of a nature or quality that likely will result in, and that it would be dangerous to proceed under section 16, the police officer may (d) serious bodily harm to the person; take the person in custody to an appropriate place for examination by a physician. (e) serious bodily harm to another person; or (f) serious physical impairment of the person, DISENGAGEMENT the physician may make application in the prescribed form for a psychiatric as- sessment of the person. Officers may use disengagement when the situation needs to be reassessed after initial contact with the mentally ill person. This option is available when Section 33 of the MHA requires that police stay with the person until the person the subject has been isolated and poses no danger to themselves or to the is admitted to the facility. public. If possible, removing potential weapons will assist in officer safety when the subject is to be removed or other options are used. While awaiting DUTY TO REMAIN AND RETAIN CUSTODY: MENTAL HEALTH ACT, SECTION 33 backup, officers should make containment of the person their primary con- cern. The negative behaviour of a person experiencing a psychotic episode is 33. A police officer or other person who takes a person in custody to a psy- unlikely to diminish while the officers wait for backup to arrive. A detailed chiatric facility shall remain at the facility and retain custody of the person until description of the behaviour of the subject should be provided to other of- the facility takes custody of him or her in the prescribed manner. ficers upon their arrival. The sharing of information is crucial in determining the next course of action.158 PARTII MENTAL ILLNESS AND SUICIDE SELF-HARM INTERVENTION CHAPTER 5 RESPONDING TO MENTAL ILLNESS 159 MENTAL HEALTH ACT: APPREHENSION we'rer to the Act for the complete text of each section. MHA Forms 1 and 2 are reprinted as Appendix , The immediate goal of intervention in cases of self-injury is to prevent the person from further self-harm. There is little that police will be able to do to provide a and 5.2 at the end of this chapter. long-term solution for the problem . SECTION 15 MHA FORM 1: APPLICATION BY PHYSICIAN FOR PSYCHIATRIC Before officers start a conversation, they should remember that one com- ASSESSMENT Milysician examines a person and determines that the person, due to an apparent mental disorder, is an monality among those who self-harm is invalidation, so they should be careful not to further invalidate the person through ill-conceived comments . or all of the following: When intervening, officers should keep the following points in mind : a danger to self Although the person is experiencing emotional distress, it is unlikely a danger to others that they are experiencing any unusual realities or a psychotic episode . unable to care for self. The physician issues a Form 1, MHA within seven days of examining the person, authorizing police to It is also unlikely that the self-harm is directed toward committing apprehend and bring the person to a psychiatric facility for examination. The form is valid for seven days suicide, although this may be a possibility. It is important that officers validate the person's feelings by accepting SECTION 16 MHA FORM 2: ORDER FOR EXAMINATION UNDER SECTION 16 that the emotional distress they are experiencing is real. They should Any person may appear before a justice and give information, under oath, that a person, due to an remember that this is different from validating the behaviour. apparent mental disorder, is any or all of the following: The person may find the presence of a police officer stressful while they a danger to self are in a state of distress. Officers should recognize that direct questions . a danger to others may feel invasive and frightening at first-particularly when coming . unable to care for self. from a person in authority. Officers should make eye contact and be The justice may issue a Form 2, MHA, valid for seven days, authorizing police to apprehend and bring respectful when speaking. They should offer reassurance and speak in the person to a physician for evaluation. calm and comforting tones. SECTION 17 MHA ACTION BY POLICE OFFICER . Officers should ask the person if there is anything that they can do A police officer has reasonable grounds to believe that, due to an apparent mental disorder, a person is any to help them with the immediate problem, with the understanding or all of the following: that their offer of assistance may be rejected. The person believes that a danger to self they have developed a coping method that will relieve the feelings of . a danger to others distress. Although destructive, self-injury does appear to lessen the unable to care for self . person's immediate distress. If, due to the immediacy of the danger, it would be unsafe for the person or the public for the officer Officers should keep in mind that people who self-injure often have to appear before a justice to obtain a Form 2, the officer may immediately apprehend the person and bring difficulty verbalizing their emotions. The person may choose not the person to a physician for assessment. to speak to the officer or may have difficulty expressing how they are feeling. If the person is not ready to address the self-harm issue, officers should choose another topic of conversation. INTERVENING WITH SELF-HARMING PERSONS Officers should not shout, lecture, or give ultimatums they don't intend AND PERSONS WITH ALZHEIMER'S DISEASE to carry out, such as "Stop hurting yourself or I will .." . Officers should avoid making statements that can make the person While not categorized as having mental illnesses, people who self-harm and those with Alzheimer's disease may present with symptoms indicative of men- feel as if their problems are trivial, such as "How can you be crazy tal illness. It is difficult for a lay person to distinguish whether the symptoms enough to do this to yourself?" or "Why would you do something indicate mental illness or not. The objective of police intervention is to prevent so stupid ? > harm or further harm. . Officers should avoid comments such as "I know how you are feeling" Officers likely don't know how the person feels .160 PART II MENTAL ILLNESS AND SUICIDE If the officer determines that the person is self-harming or poses a dange. to themselves or others as a result of a mental disorder, the provisions of for CHAPTER S RESPONDING TO MENTAL ILLNESS 161 Ontario Mental Health Act may be applicable. The officer may need to appreh he Although these treatment options may offer some benefit , none has been proven the person and bring them to a physician. This type of action may be necesend to effectively prevent self-harm from recurring . is an interim measure to prevent further harm. If the person is non-suicidal, referring to the appropriate community ro RESPONSE WHEN PERSON HAS ALZHEIMER'S DISEASE sources may be an option. Alzheimer's disease is a progressive, degenerative disease that destroys brain cells SELF-HARM TREATMENT OPTIONS and causes dementia. It can strike adults at any age, but is most common in per- sons 65 and older. Some of the signs of Alzheimer's disease include: Several treatment options are available to help the self-injurer control their memory loss that affects day-to-day functioning behaviour: . difficulty performing familiar tasks Therapy: Therapies usually focus on helping the person tolerate . problems with language greater intensities of emotions without resorting to self-harm and . chronological and spatial disorientation on developing their ability to articulate their emotions and needs. . decreased powers of judgment The patient learns alternative, healthy ways of discharging their eelings of distress through problem solving, conflict resolution, anger problems with abstract thinking management, and assertiveness training. . misplacement of possessions The two main type of therapies used are: changes in mood or behaviour Cognitive behaviour therapy (CBT). These types of therapies . changes in personality address issues such as anxiety and depression, as well as other mental . loss of initiative. health concerns. The objective is to help the person become aware of inaccurate or negative thinking, so they can see challenging The officer should check to see whether the person is registered with a program situations more clearly and respond to them more effectively. A such as the MedicAlert Safely Home program or a vulnerable persons' regis- specific type of CBT called dialectical behaviour therapy is used with try supported by police services. Each registrant in such programs is issued an individuals who self-harm. identification bracelet and card on which pertinent information is recorded. The Problem management therapy. This type of therapy focuses information will identify the person(s) to contact if the registrant needs assist- on identifying specific problems that an individual is facing and ance. If the person is not in the registry and is unable to articulate their name assisting with helping the person generate positive solutions to these and address and appears to be unable to care for themselves, they may require problems. assistance. The provisions of the MHA may be applicable. It is difficult for a non-medical professional to distinguish between the symptoms of Alzheimer's . Medication. Persons who self-harm and suffer from moderate disease and those of a mental illness. When in doubt, the officer should be cau- or severe clinical depression may respond to treatment with tious and protect the person from possible harm by apprehending and bringing antidepressant drugs. hem to a physician for examination. Hospitalization. This type of treatment is a last resort. The main goal of hospitalization is to prevent self-injurers from hurting themselves, albeit in an artificially safe environment. However, in such a controlled EXCITED DELIRIUM environment, the person has less freedom and more supervision. This In some situations it is possible that a person may die suddenly and unexpect- over their lives . may be viewed as taking away any remaining semblance of self-control edly while in police custody. There does not appear to be any apparent injury or excited delirium Treatment in such an environment is not likely to be effective. The cause of death. These deaths may be attributed to a group of symptoms called excited delirium. Death as a result of excited delirium occurs once a subject is state of acute agitation person needs to learn to cope with their feelings of distress and react in and hyperactivity, usually accompanied by violent a less destructive manner without external control. "successfully" restrained, possibly within five minutes of the subject becoming quiet. There are no indicators preceding the death. behaviour162 PART II MENTAL ILLNESS AND SUICIDE Death due to excited delirium is not a police-specific phenomenon. Similar CHAPTER 5 RESPONDING TO MENTAL ILLNESS 163 deaths occur in psychiatric and geriatric care facilities where patients are fit bizarre, purposeless, and violent behaviour quired to be restrained for their safety. Persons suffering from a psychiatric hyperactivity illness may be at higher risk of death as a result of excited delirium. pelatric incoherent shouting or screaming experiencing excited delirium are in a state of acute agitation and hyperactivens which is usually accompanied by violent behaviour. No definitive cause has yet - failure to recognize or acknowledge police presence been identified, but persons experiencing psychotic episodes and persons under. - extreme aggression the influence of drugs, most notably cocaine, appear to be at greater risk, paranoia . Police officers should be aware that persons experiencing manias as a result of a psychiatric illness or drug-induced psychosis often present the same symal 3. Physical contact with the individual. Upon physical contact, the officer may note any or all of the following : toms and behaviours as persons experiencing excited delirium. It is therefore almost impossible to accurately determine causation during an encounter. The subject demonstrates unbelievable strength that appears to be There are some signs and symptoms that may indicate excited delirium: outside their physical characteristics. The subject is apparently impervious to pain. There is no response to . violent/aggressive behaviour pain compliance techniques. disorientation The subject is able to physically resist multiple officers without becoming tired. hallucinations to boom ni esgoads . panic The subject is sweating profusely, or the subject's skin is extremely dry. paranoia When apprehending a person with a mental disorder, officers should be aware . impaired thinking of the increased possibility of excited delirium. In situations involving extremely . diminished sense of pain agitated people, physical restraint is often necessary but should be used only unexpected physical strength when the situation clearly justifies it and when there is no other way to prevent apparent ineffectiveness of oleoresin capsicum (OC) spray, or pepper physical harm to the person or to others. Restraint is not harmless; some of those who are restrained may experience the adverse effects of excited delirium. The spray (a second application may be detrimental to the subject) time spent under restraint should be minimized. Successfully placing the person . profuse sweating in restraint is not an end in itself, but rather the first step in a process of calming . sudden tranquility after aggressive actions. the person and resolving the situation. Appropriate techniques for restraint that minimize the use of chest compression and the prone position and that maintain The final six of these symptoms appear to be common in individuals deemed an open airway should be used whenever possible. The restraining officers must to be experiencing excited delirium. take care to not induce positional asphyxia. Positional asphyxia may occur when There is no set of criteria for establishing a diagnosis of excited delirium a person is restrained in the prone position with the officer using their body However, there is some useful information that may assist with identifying the weight on the subject's chest or back as a method of control. possibility of excited delirium occurring. People in a state of excited delirium may have a greater oxygen requirement, 1. Pre-encounter descriptions from witnesses. Information may be predisposing them to rapid asphyxiation if placed in a position, such as the prone available prior to the police encounter that suggests that excited position, that inhibits their breathing. This belief has been reinforced through delirium may be present, particularly if the incident is violent in coroners' rulings of positional asphyxiation as the cause of death in suspected nature. This information may include: cases of excited delirium. Positional or postural holds are the restraints most frequently associated with unexpected death in persons susceptible to excited known history of schizophrenia, psychosis, or mania delirium. known or suspected history of substance abuse. The position that appears to be most detrimental is face down with feet and 2. Officer's observations upon arrival at the scene. Once the officer is on hands cuffed together behind the person (commonly referred to as "hog-tying" ). the scene, any or all of the following may be observed: If possible, police should not use this restraint method to control people show- ing signs of excited delirium. Positioning the restrained person in a manner that164 PARTII MENTAL ILLNESS AND SUICIDE how's unrestricted breathing, such as sitting, may be helpful in preventing up CHAPTERS RESPONDING TO MENTAL ILLNESS 165 anticipated death. the reasons for sudden and unexpected excited delirium deaths are compley . Once the subject is in custody and awaiting, transport via ambulance, chris Lawrence (Ontario Police College), working with medical experts such ? or is being transported in the ambulance, the officer should place Wanda Mohr (associate professor, Psychiatric Mental Health Nursing, Univer as the restrained subject in a supine position. If the subject must be of Medicine and Dentistry of New Jersey), has been conducting groundbreakity maintained on their side, it is recommended that the officer place them resting on their left side if possible . research into the medical literature on excited delirium. According to the medical literature reviewed for the report Investigator If the restrained subject suddenly becomes quiet and stops resisting, Protocol: Sudden In-Custody Death (Lawrence & Mohr, 2004), there appear to or the officer should summon advanced life support where available and prepare for CPR. (nice specific groups of people who are most prone to sudden and unexpected death attributed to excited delirium: 1. individuals who are suffering from psychiatric illness, specifically bipolar disorders and schizophrenia (this is also noted in a study where both agitated and non-agitated subjects suffering from schizophrenia LEARNING SCENARIOS died suddenly and unexpectedly [Rosh, Sampson, & Hirsch, 2003 ) 2. individuals who are chronic users of illicit stimulants LEARNING SCENARIOS 5.1 3. individuals who combine the two previous risk factors. you are a police officer responding to a call for assistance at 789 Main Street. Upon arrival you are met by Pete Herman and Wendy Herman. Pete is very emotional and is crying. As noted previously, the deaths of some individuals while in police custody have been attributed to excited delirium. Evidence, while inconclusive, suggests three days. "Wendy tells you that she is scared of Pete. He has been having delusions and hallucinations for the past You speak to Pete. that physical restraint in certain positions may contribute to such deaths. The use He explains to you that he sometimes sees a black dog. The dog talks to him and tells him that he of OC spray may also be a contributing factor in some of these deaths. should be having sex with children. He is confused because the dog has never lied to him before, but he In most instances, excited delirium was likely the result of a pre-existing psy. doesn't think it is right for adults to have sex with children. Pete tells you that he went to Dr. Kay about a chiatric illness. In a significant number of cases, it resulted from recent cocaine year ago to get help. He told Dr. Kay about his hallucinations and that he believes that he may have sexu- ally touched his two-year-old daughter. use. Other factors contributing to death during excited delirium include heart Dr. Kay began counselling Pete and prescribed anti-psychotic drugs for him. disease and obesity. Pete tells you that it has been almost a year and nothing has changed. The therapies aren't working The dog is around more than ever. It won't shut up. Lawrence (2004) suggests that some measures may be taken to enhance the safety of a person who is about to be, or who has been, taken into custody through What will you do in this situation? Explain your answer . physical restraint and is exhibiting signs or symptoms of excited delirium: LEARNING SCENARIO 5.2 If possible, advanced life support paramedics should be on standby You are a police officer on foot patrol of the downtown area of the city. It is 5 p.m. You observe a person before physically restraining a person who appears to be experiencing lying beside a dumpster behind a restaurant. As you approach the person, you recognize him as Joe Keith. excited delirium. Mr. Keith is homeless and an alcoholic. You shout to get his attention. He sits up. You ask him what he is doing. . Excited delirium is a medical emergency-all subjects should be He tells you that sometimes restaurants throw away their empty liquor bottles. If he can find a few of transported to hospital via ambulance. them and pour the liquor that is still in the bottoms of the bottles together, he can get a good drink. He tells you that the most beautiful sight he has seen was a half-bottle of wine he found last week when he . From a control and safety perspective, it is best to control the subject as was checking dumpsters. You ask him to stand up. He tells you that he has a bad leg and can't stand or walk very well. He pulls quickly as possible. It may be that the longer the physical confrontation up his pant leg and shows you a large cut on his calf. He tells you that a rat told him that blood was just goes on with a subject experiencing excited delirium, the higher the like red wine, so he cut himself to find out. He tells you that the "eff'n rat was lying!" risk of an in-custody death. You ask if he wants to go to the hospital to get his leg checked. He replies: "Maybe in a few days. It's Friday night, the best night of the week to get booze. I don't want to go to the hospital tonight." He asks . Given the correlation between the maximal restraint position (hog- you if you can lend him a few dollars to get a drink. He hasn't had a drink since last night and is feeling tied) and sudden and unexpected death, the use of this restraint pretty rough. He just needs a couple of drinks to "take the edge off." position should be used with extreme caution. (Follow police service What will you do in this situation? Explain your answer. Be sure to quote authorities. guidelines.)148 PART II MENTAL ILLNESS AND SUICIDE CHAPTER 5 RESPONDING TO MENTAL ILLNESS 149 INTRODUCTION Police officers who must intervene with persons experiencing symptoms of . Always make officer safety a major consideration. Do not become mental illness face several challenges. The majority of symptoms experience complacent. It is unlikely that the presence of police officers will calm the person. It is more likely, if the person is delusional or paranoid, by mentally ill persons may be difficult for officers to identify. It may be difficult that they will interpret the presence of police officers as evidence of to communicate with persons experiencing altered states of mind. Some ment conspiracies against them . tally ill persons may become violent. This chapter will identify provisions of the Mental Health Act (MHA) of Ontario regarding police authorities and respons Watch for rapid movement of the eyes or head, which may indicate that the person is visually hallucinating. Ask the person if they sibilities. It will also discuss safety and effective intervention techniques. are seeing or hearing anything or anyone. If so, ask what they are seeing or hearing. Try to determine the "message" that the person POLICE INTERVENTION s receiving. Ask yourself: Is the person likely to react violently to the message ? As first responders, the police are often called upon to manage situations in- volving persons with mental illness. While the police may function primarily . Ask the person what type of assistance they require. Reassure the subject as a conduit in these cases, connecting the persons involved with the services that police are there to help, provided that the person is not so deeply involved in the delusion that such reassurance will be ineffective. If of appropriate professionals to help them, such situations also call on police to exercise their power and authority in safeguarding the welfare of the public. The the person indicates that they cannot control their actions, explain following are some suggestions that may be useful in engaging in effective and that police can help if required. If requests for assistance are not safe interactions with individuals who have a mental illness. forthcoming, offer suggestions such as seeing a doctor or other persons who may be able to help. If the person begins to speak rapidly, request that they slow down. Such INTERACTING WITH PERSONS IN A a request may reinforce delusions of intellectual superiority, but it is HALLUCINATORY/DELUSIONAL STATE necessary to try to ascertain the direction of the person's thoughts. If The subject may experience delusions and hallucinations simultaneously. the person does not respond to the request, ask specific questions such Interaction with a person in a delusional/hallucinatory state may prove difficult as their name, address, or date of birth, or other questions that require for police. The following are some suggestions to ensure the safety of the officer specific answers. The purpose of such questioning is to try to force the and the subject during such interactions. person to slow down and think about the question. . Pay particular attention to the person's non-verbal messages. Clenched Remain aware that the subject perceives the delusion or hallucination fists, clenched teeth, and stiff or rapid movements may be indicators as real. The person believes that they are experiencing everything they see or feel in the hallucination. If the person is delusional, of potential violence. Or, if the person is non-responsive, they may the departure from normal, rational thought processes convinces display passive behaviour, not speak, and stand motionless. the person that the delusion is real. Trying to convince the person . If the officer decides to apprehend the person under the authority of otherwise will likely be unproductive . section 17 of the Mental Health Act, they should tell the person of their . Tell the person that you are there to help. The person is attempting intention. They should inform the person that he or she is being to interact within separate realities . Allow for delays in responses . apprehended but keep in mind that there is the possibility of a violent If the person asks whether you are experiencing the hallucination reaction or refusal to cooperate. If the officer has adhered to safety or delusion, do not mislead the person by saying that you are. This precautions, such as removing access to weapons and ensuring the will reinforce the reality of the experience or lead the person to availability of backup, they should more easily manage the level of believe that you are deceiving them when you are unable to interact potential violence. If the person is unwilling to accompany police to with the imaginary persons or objects in the hallucination. This loss the hospital, the officer should explain that the issue is not debatable. the subject. of credibility will hamper your ability to positively interact with Police may allow the person to retain some semblance of control by allowing them to make non-crucial decisions such as the choice of transportation by ambulance or police vehicle.4:19 8 9 8 . NO 49 1 40% B Q