Transcript Lessons Learned from a CIT Call Gone Bad

LESSONS LEARNED FROM A
CIT CALL GONE BAD
Steve Hobart
CIT International Conference
22 August 2012
Outline/Agenda
 Introduction
 The CIT Call
 Lessons Learned
 For patients, caregivers and advocates
 For the mental health professional community
 For those who respond to calls for CIT service
 Workshop: Refining of Lessons Learned
Introduction
 Talk is dedicated to the memory of my son, Aaron Hobart.
 While in the throes of a mental health crisis, Aaron was
killed by a confused police officer who claims to have
feared for his life in his encounter with Aaron.
 Talk is motivated by a desire to prevent similar tragedies.
 For the purposes of this workshop, the “CIT call” is a
request for crisis intervention team assistance from a
caregiver on behalf of a loved one having a mental health
crisis.
Brief Bio of Aaron (1)
 Born in 1989. Died at age 19.
 Minor birth complications.
 Tended to over-focus on things.
 Label of Aspberger Syndrome.
 IQ = 129
 Legomaniac: aspired to be an architect
 Sensitized to poverty and injustice on mission trip to
Mexico
Brief Bio of Aaron (2)
 Held jobs at Whataburger, YMCA
 Lifeguard at church retreats
 Poet, Musician and “Metaphysician”
The CIT Call
The Call for a CIT Officer (1)
Slightly edited transcript
Dispatcher: … 911. What’s your emergency?
Pam Hobart: I have a son that needs to be taken … he’s becoming very violent … I need
a CIT officer.
D: Where’s this at? What’s your address?
PH: 12127 Aspen Lane
D: What’s he doing?
PH: … um … Well he’s been … um … he’s deteriorating … he’s becoming delusional … um
… he’s not hurting anyone but … he needs to be in a hospital. He needs medication.
(…)
D: Where’s he at now? Is he at the house?
PH: He’s in our home. Yes. … My husband’s here.
D: OK. I’m going to send an officer out there.
The Call for a CIT Officer (2)
Slightly edited transcript
PH: And he’ll be able to help us to transport him?
D: Yes.
PH: OK. Thank you. … How long will that be?
D: Depends on traffic
PH: Oh, OK. Thank you very much. [End call #1]
(Call #2, about 2 minutes later)
D: Ms. Hobart. … This is J__ with the Police department. How old is your son?
PH: 19
D: OK. We have officers on the way. They just wanted to know that.
The Call for a CIT Officer (3)
Slightly edited transcript
PH: OK. What’s the procedure?
D: They’ll have to explain that to you when they get there. Um … they were just asking
me a couple of questions while they were still on their way out there.
PH: Sure. Sure. OK.
D: Alright? No problem. Is he still in his room?
PH: Yes. My husband’s in there with him, but he’s becoming more and more belligerent
and … um …
D: OK. Your husband’s in the room with him now?
PH: Yes.
D: OK. I’ll let them know about this information.
PH: OK. Thank you. [End call #2]
The Call for a CIT Officer (4)
Slightly edited transcript
(Call #3, about 1 minute later)
D: Ms. Hobart? … This is J__ again. Are there any weapons in his room or anything?
Does he have any?
PH: No, no. He’s got a drum set in his room.
D: OK. He’s not under the influence, is he?
PH: No.
D: OK. These are just … a couple of questions the officers were asking.
PH: We just want to transport him as soon as possible.
D: Has he done this before?
PH: He was hospitalized a year and a half ago, but that was something where he was
driving at night. He took one of our cars and was stopped for reckless driving.
D: OK. Well, they’re almost there. PH: Well, Thank you. [End call #3]
Record from Officer’s Dash-Cam Audio
15:07:40-43
Officer: “Tell RP to step outside”
15:08:00-03
(sound of door opening) PH: “Come in?”
15:08:09-12
PH: “You’re with the police?”
Officer: “Yes.”
15:08:12-15
(More talk, words not distinct on radio recording. Recollection was
PH: “I’m glad you’re here.”)
15:08:15
Start of “Stop … Stop” (both PH and Officer, according to statements)
5 seconds of scuffle
15:08:20-22
Six shots fired.
15:08:23-24
Officer: <Cursing>
15:08:25
Officer: “224 shots fired”
Nobody wanted the call to end this way.
What went wrong?
The Call for a CIT Officer (Hindsight 1)
Slightly edited transcript
Dispatcher: … 911. What’s your emergency?
Pam Hobart: I have a son that needs to be taken … he’s becoming very violent … I need
a CIT officer.
D: Where’s this at? What’s your address?
PH: 12127 Aspen Lane
D: What’s he doing?
PH: … um … Well he’s been … um … he’s deteriorating … he’s becoming delusional …
um … he’s not hurting anyone but … he needs to be in a hospital. He needs
medication.
(…)
D: Where’s he at now? Is he at the house?
PH: He’s in our home. Yes. … My husband’s here.
D: OK. I’m going to send an officer out there.
The Call for a CIT Officer (Hindsight 2)
Slightly edited transcript
PH: And he’ll be able to help us to transport him?
D: Yes.
PH: OK. Thank you. … How long will that be?
D: Depends on traffic
PH: Oh, OK. Thank you very much. [End call #1]
(Call #2, about 2 minutes later)
D: Ms. Hobart. … This is J__ with the Police department. How old is your son?
PH: 19
D: OK. We have officers on the way. They just wanted to know that.
The Call for a CIT Officer (Hindsight 3)
Slightly edited transcript
PH: OK. What’s the procedure?
D: They’ll have to explain that to you when they get there. Um … they were just asking
me a couple of questions while they were still on their way out there.
PH: Sure. Sure. OK.
D: Alright? No problem. Is he still in his room?
PH: Yes. My husband’s in there with him, but he’s becoming more and more belligerent
and … um …
D: OK. Your husband’s in the room with him now?
PH: Yes.
D: OK. I’ll let them know about this information.
PH: OK. Thank you. [End call #2]
The Call for a CIT Officer (Hindsight 4)
Slightly edited transcript
(Call #3, about 1 minute later)
D: Ms. Hobart? … This is J__ again. Are there any weapons in his room or anything?
Does he have any?
PH: No, no. He’s got a drum set in his room.
D: OK. He’s not under the influence, is he?
PH: No.
D: OK. These are just … a couple of questions the officers were asking.
PH: We just want to transport him as soon as possible.
D: Has he done this before?
PH: He was hospitalized a year and a half ago, but that was something where he was
driving at night. He took one of our cars and was stopped for reckless driving.
D: OK. Well, they’re almost there. PH: Well, Thank you. [End call #3]
Record from Officer’s Dash-Cam Audio (Hindsight)
15:07:40-43
Officer: “Tell RP to step outside”
15:08:00-03
(sound of door opening) PH: “Come in?”
15:08:09-12
PH: “You’re with the police?”
Officer: “Yes.”
15:08:12-15
(More talk, words not distinct on radio recording. Recollection was
PH: “I’m glad you’re here.”)
15:08:15
Start of “Stop … Stop” (both PH and Officer, according to statements)
5 seconds of scuffle
15:08:20-22
Six shots fired.
15:08:23-24
Officer: <Cursing>
15:08:25
Officer: “224 shots fired”
So … What went wrong?
Why Did This CIT Call Go Bad?
In one word:
Preparation
1. We were not prepared to deal with the
police.
2. The police were not prepared to
properly handle a CIT call.
Lessons Learned
Lessons for persons at risk of a brain disorder crisis (1)
Bad News – Good News
Bad news:
You are at risk if you have had an
“episode” in the past.
Good News:
You are not alone in this.
Lessons for persons at risk of a brain disorder crisis (2)
Your disorder is not your fault.
You didn’t cause it.
You didn’t ask for it.
You didn’t do anything to deserve it.
It is your body, your disorder, your life, your responsibility.
You are accountable for what you do with it.
You have to learn to manage it.
You need to plan for a possible “episode”.
Failure to plan is planning to fail. Failure can cost you your life.
Lessons for persons at risk of a brain disorder crisis (3)
To manage your disorder, you need to learn about it.
Diagnoses are often based primarily on interpretation of
observed symptoms, rather than identification of specific
causative factors.
Ritsner, M., “Is a Neuroprotective Therapy Suitable for Schizophrenia Patients?”, in M. Ritsner ed. “Brain Protection in Schizophrenia, Mood and Cognitive Disorders”.
Vulnerability – Stress Model for Mental Illness
Current paradigm for psychiatric brain disorders is that a combination of
vulnerability and stress leads to the manifestation of symptoms and additional
damage to the brain.
Vulnerabilities and stressors can include: genetics, glandular problems, nutrition,
trauma, toxins, infections, psychosocial stressors, birth complications and more.
from Ritsner
Some “Non-Psychiatric” Conditions Associated With Psychosis
Some causes are more treatable than others.
Anti-psychotics are not always the answer.
White et al., American Journal of Psychiatry, 163:3, March 2006
See also: http://en.wikipedia.org/wiki/Psychotic_disorders#Psychiatric_disorders
Managing Your Brain Disorder
• How has it manifested itself? What changed during a crisis?
• Perception of reality: Examples: Paranoia? Voices? Hallucinations? Delusions of
Grandeur? Alternate personality?
• Attitude about yourself: Examples: Mania? Depression? Suicidal thoughts?
Omnipotence?
• Attitude toward others: Examples: Fear? Belligerence? Withdrawal? Shame?
Suspicion?
• Behavior: Examples: Pacing? Skipping meals? Skipping regular personal hygiene?
Hoarding? “Bizarre” activities?
• What may have indicated that a crisis could be imminent?
• Sleeplessness? Frenetic activity? Reclusiveness? Recurrent or obsessive
thoughts? Change in daily habits?
• What can you do about it?
•
•
•
•
Consult with a psychiatrist
Prescribed medications (self-medication is a prescription for problems)
Therapy
Investigate possible vulnerabilities, causes or “triggers”
Lessons for persons at risk of a brain disorder crisis (4)
You need to plan for an eventual crisis, even though it may be
scary to even consider the possibility:
• Anti-psychotics generally do not cure brain disorders.
• Anti-psychotics can reduce the frequency of crises, but likely
will not eliminate them altogether.
• Various forms of psychotherapy can help in self-awareness
and coping with the illness, but they do not address the
underlying biological disorder.
If you do not pre-plan for a crisis, others will have
to make decisions for you when it occurs. The
urgency of the situation will likely lead to suboptimal decisions, despite the best intentions.
Elements of a Sample Crisis Plan
Credit NAMI Minnesota: http://www.namihelps.org/Crisis-Booklet-Adults.pdf
Further Elements of a Mental Health Crisis Plan (1)
Must keep in mind the goal:
Get to the “other side” of the crisis
with no harm to yourself or others.
Know who is going to be involved in responding to your crisis.
• Caregiver(s)
• Doctor(s): primary care, psychiatrist, admitting doctor
• Transport personnel: police department or specialty
transport services
• How will the call for help be routed and dispatched?
• Who will be dispatched? What will be their training? Are
they equipped to do the job? Will they seek to preserve
your comfort and dignity?
• Justice of the Peace: How can Mental Health Warrant
process be expedited?
Flowchart for Deployment of Mobile Crisis Outreach Team
Further Elements of a Mental Health Crisis Plan (2)
Must keep in mind the goal:
Get to the “other side” of the crisis
with no harm to yourself or others.
Discuss, preferably in person with each potential team member, what you
can expect each member of your team to do in responding to your crisis.
• Get feedback: Is your plan realistic?
• Will they honor your plan?
• Contingencies: e.g. What if there are no beds? What if a part of your
“team” is unavailable at the time of crisis?
Further Elements of a Mental Health Crisis Plan (3)
Crisis kit (for patient and caregiver):
 Physical:
• Toiletries,
• Comfortable change of clothes
• Reading material and/or music with earphones
• Other medications, snacks (consider shelf life)
 Documentation:
• Medical and psychiatric records
• Prescription history
• Insurance documents
• Medical (or full) power of attorney or guardianship papers
• HIPAA (and state) release forms
• Crisis plan notes and documents
• Copies of previous mental health warrants or other legal
matters
• Certificate of Medical Examination
• Partially filled-out mental health warrant
Caregivers (1)
1. Help loved one take responsibility for life decisions.
• Matter of maturity and necessity
• Encourage development of appropriate treatment or
management strategy in line with loved one’s life goals.
• Encourage investigation of possible causes or triggers for
mental health crises.
2. Encourage socialization, education and employment
3. More autonomy for your loved one
• Autonomy is a consequence of taking responsibility
• Reduces interpersonal stress
• Shows respect (dignity)
• Can enrich life experiences
• May even lead to healthy independent living (hope)
Caregivers (2)
Do not assume that there will not be another episode.
Plan for another episode. Odds are that it will happen.
Do not assume adhering to medication regime will prevent a
recurrence. In general, medication may reduce, but not eliminate,
risk of another episode.
Work with loved one on his/her plan.
Suggestions for augmenting your loved one’s plan:
• Have back-up medication (consider shelf life)
• Get to know the CIT officers in your jurisdiction
• Know what resources are available
• Know where you want to take your loved one
• Have information ready for dispatcher and CIT officer
• Have insurance information available
Caregivers (3)
A mental health crisis can entail complex legal issues. These need to be included
in crisis planning. Consider finding an appropriate lawyer ahead of time. Laws
and procedures may vary from one jurisdiction to the next.
The laws are written to protect the rights of patients. Oftentimes, they presume
that a conscious patient is competent.
• Guardianship, Medical power of attorney and/or Durable Power of Attorney
(These only permit you to consent on behalf of your loved one for medical
treatment and psychiatric exams, not for commitment.)
• HIPAA release
• Learn the local laws and procedures:
o Emergency detention
o Mental health warrants
o Voluntary admission for mental health services
o Court-ordered mental health services
Caregivers (4)
Your loved one may enter a crisis in a public situation.
Obliviousness to the social setting may result in an
arrest for “disorderly conduct”, disturbing the peace,
trespassing or some other charge.
There is a potential for escalation, especially if they resist arrest or otherwise
fail to give sufficient deference to an officer’s authority.
If your loved one is not diverted from the criminal justice system into
appropriate care:
o Protecting your loved one’s legal rights, e.g. to remain silent or have an
attorney present during questioning, may become problematic.
o Access to psychiatric care and all medications may be delayed for
several days, even if all the protocols are understood and observed.
o What to do about possible criminal arrest record? Impact on career
prospects, etc.
Some Potential “Gotcha’s” for Consumers and Caregivers
(1) Some entities calling themselves “crisis intervention”
responders are actually providers of psychological
counseling services for people having life crises (e.g.
home loss due to a hurricane). They are not prepared to
be primary responders to people having psychiatric
emergencies.
Know your crisis support team!
(2) There are some situations under which a “Mobile Crisis”
unit will not respond.
• Situation insufficiently severe to warrant assistance
• Situation sufficiently dangerous to warrant use of a
trained peace officer
Psychiatrists
 Work with patient and caregiver to determine
cause of illness
 Do not assume the cause
 Eliminate as many causes as possible.
• Toxins
• Tumors
• Trauma
• Endocrinology, etc.
 Respect patient’s right to choose, but be as
informative and persuasive as possible
regarding the most appropriate course of
action.
 Work with caregiver and patient to plan for another possible
episode
 Community and crisis response resources
 Treatment facility options
 Emergency medication plan
 Obtain admitting privileges
 Certificate of medical examination (TX)
Hospitals that Receive Mental Health Patients
 Strive to keep at least one bed
available for psychiatric patients.
 Be liberal in granting admitting
privileges to psychiatrists who
treat patients with serious brain
disorders.
 Have a mental health
professional on call at all times.
Note: psychiatric emergencies do not observe 9-5 working hours or holidays.
Local Governments
 Actively ensure all departments are
complying with the letter and spirit of
ADA, especially in areas where it can
make a difference between life and
death.
 Take advantage of assistance and
information available from the US
Department of Justice and other
organizations.
 Consider the liability risk of not
having CIT.
Police Chief / Police Department (1)
Implement a plan for “Crisis Intervention” calls.
• Numerous resources available.
• Many examples of CIT programs already implemented.
o There is no need to “re-invent the wheel”.
o Examples: Memphis model, co-responder model
o The program specifics will have to be tailored to local
needs and resources.
• Best plans have the support of local governments, the
mental health community and consumer / caregiver buyin.
Police Chief / Police Department (2)
CIT call response requires a coordinated team effort.
Make up of team depends on local resources
• Mental health specialist (if available)
• CIT Officer – leader of the team if no mental health professional
• Back-up officers (no solo CIT call responses)
• Call taker / Dispatcher
• Caregiver at the scene (!)
Police Chief / Police Department (3)
The public needs to know what to expect from your CIT program
o Especially consumers, caregivers, counselors and
psychiatrists
o Encourage CIT officers to assist consumers in
development of their crisis plans
o Website a source of information and good public relations
(e.g. Houston, Memphis and others)
Police Chief referring
to state-mandated 16hour “CIT training” at
the police academy.
Police Chief / Police Department (4)
Establish General Orders for CIT Officers, support officers (no
solo CIT calls), call takers and dispatchers in how to handle
calls requiring CIT service.
Ensure that the General Orders are up-to-date with respect
to the all laws, including case law, as well as best practices.
Require all officers and dispatchers to become familiar with
the General Orders.
- Call Taker / Dispatcher
Police Chief / Police Department (5)
Ensure that your personnel are adequately trained
o No gaps in the academy training and Field Training.
o Field training should include supporting role in mental health call
scenarios.
o Call takers / dispatchers should be trained to field calls from the
mentally ill or their caregivers as well as from persons with a
complaint about the behavior of a possibly mentally ill person.
- Responding Officer
- Call Taker / Dispatcher
Police Chief / Police Department (6)
Suggested Competencies for CIT Call Response
(Not intended to be an exhaustive list)
“CIT Officer”:
 Trained, empathetic, motivated, experienced leaders
 CIT is a specialty, just like SWAT is a specialty
 Primary concern is safety of all people at the scene
 Can comfortably and respectfully work with all personnel involved:
the team, mental health personnel, caregivers, consumers, judges
 At least 40 hours specialist training
 Need to know how to direct a team (always have back-up)
 Needs to retain authority even if more senior, but less qualified,
officers arrive (e.g. Nagle/Casey case, another call gone bad) as long
as the mission is a crisis intervention.
 Has pre-arrival briefing with team
 Consults with caregiver at the scene
 Conducts drills and post-mission reviews with team
 Equipped with full range of less than lethal options
Police Chief / Police Department (7)
Suggested Competencies for CIT Call Response
(Not intended to be an exhaustive list)
CIT Officer back-up:
 A CIT call should not be a solo operation
 Back-up team members need to know their roles
 Back-up can be over-zealous to protect one another (e.g. Meadours
case, another call gone bad)
 Understand elements of CIT Officer briefing
o What is known and interpreted about the situation
o Safety guidelines
o Verbal signals
• When to have force at the ready
• When to deploy a particular form of force or restraint
 Trained and equipped for multiple non-lethal custody-taking
techniques
Police Chief / Police Department (8)
Suggested Competencies for CIT Call Response
(Not intended to be an exhaustive list)
Call-taker / Dispatcher:
 Knows how to determine if a call requires a Crisis
Intervention Team
 Knows how to handle calls requiring CIT services
o Proper dispatching
o Obtaining the right information from the caller
o Instructing the caller on what to expect
o Coaches caller in keeping situation stable
o Participates in drills
Police Chief / Police Department (9)
Foster a mentoring / learning atmosphere:
•
•
•
•
Post-action reviews
Compile and disseminate lessons learned
Continually update documented best practices
Supplementary training
- Responding Officer
- Call Taker / Dispatcher
Post-Action Review: CIT International Example Incident Tracking Form
http://www.citinternational.org/images/stories/CIT/SectionImplementation/Outcomes/TrackFormCITINT.htm
For Everybody Involved
Common Goal: to compassionately secure assistance to people in a brain
disorder crisis in order to prevent harm to themselves and to others.
Components of a compassionate community
• Without participation of consumers and caregivers, there is no need to
bother with CIT.
• Without mental healthcare resources, there is no need to bother with CIT.
• There is no CIT without trained responders.
Communication
• Lay people, police, trained medical personnel don’t always speak the same language.
• Trigger words: “violent”, “afraid”, “danger”, “risk”
Compassion
• People suffering from brain disorders need help, not hardship.
Cooperation
• A call for assistance from a caregiver or a person in crisis is generally not a request to
put someone in jail or to inflict pain or injury on anyone.
• Caregivers and CIT responders need to cooperate when possible in safely securing
appropriate care for the person with a brain disorder crisis.
A Caregiver’s Perspective
Primary concerns for their loved one:
1. Safety
2. Health
3. Comfort
4. Dignity
Apart from the consumer, the caregiver has the most “skin-in-the-game” and is
extremely anxious to ensure that everything goes well for their loved one.
In the absence of a breach of the law, the mentally ill person is not a “suspect”
or a “perp”.
When CIT call responses involve uniformed officers arriving in police cars with
flashing lights, taking a family member away in handcuffs (or on a stretcher),
this creates a disincentive to requesting CIT “services”.
Failure to irreproachably execute a CIT mission can severely damage trust in
the system by the consumer/caregiver community.
“Killing is unnecessary”
Workshop
• Constructive criticism – brief to allow more participation
• Your most important item
• Will edify everyone present – THANK YOU !!!
• Will improve future presentations – THANK YOU !!!