L ESSONS L EARNED FROM A CIT C ALL G ONE B AD Steve Hobart CIT
International Conference 22 August 2012
Slide 2
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
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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.
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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
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Brief Bio of Aaron (2) Held jobs at Whataburger, YMCA Lifeguard
at church retreats Poet, Musician and Metaphysician
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The CIT Call
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The Call for a CIT Officer (1) Dispatcher: 911. Whats your
emergency? Pam Hobart: I have a son that needs to be taken hes
becoming very violent I need a CIT officer. D: Wheres this at?
Whats your address? PH: 12127 Aspen Lane D: Whats he doing? PH: um
Well hes been um hes deteriorating hes becoming delusional um hes
not hurting anyone but he needs to be in a hospital. He needs
medication. () D: Wheres he at now? Is he at the house? PH: Hes in
our home. Yes. My husbands here. D: OK. Im going to send an officer
out there. Slightly edited transcript
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The Call for a CIT Officer (2) PH: And hell 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. Slightly
edited transcript
Slide 9
The Call for a CIT Officer (3) PH: OK. Whats the procedure? D:
Theyll 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 husbands in there with him, but
hes becoming more and more belligerent and um D: OK. Your husbands
in the room with him now? PH: Yes. D: OK. Ill let them know about
this information. PH: OK. Thank you. [End call #2] Slightly edited
transcript
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The Call for a CIT Officer (4) (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. Hes got a drum set in
his room. D: OK. Hes 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, theyre
almost there. PH: Well, Thank you. [End call #3] Slightly edited
transcript
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Record from Officers Dash-Cam Audio 15:07:40-43 Officer: Tell
RP to step outside 15:08:00-03(sound of door opening) PH: Come in?
15:08:09-12PH: Youre with the police?Officer: Yes. 15:08:12-15(More
talk, words not distinct on radio recording. Recollection was PH:
Im glad youre here.) 15:08:15Start of Stop Stop (both PH and
Officer, according to statements) 5 seconds of scuffle
15:08:20-22Six shots fired. 15:08:23-24Officer: 15:08:25Officer:
224 shots fired Nobody wanted the call to end this way. What went
wrong?
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The Call for a CIT Officer (Hindsight 1) Dispatcher: 911. Whats
your emergency? Pam Hobart: I have a son that needs to be taken hes
becoming very violent I need a CIT officer. D: Wheres this at?
Whats your address? PH: 12127 Aspen Lane D: Whats he doing? PH: um
Well hes been um hes deteriorating hes becoming delusional um hes
not hurting anyone but he needs to be in a hospital. He needs
medication. () D: Wheres he at now? Is he at the house? PH: Hes in
our home. Yes. My husbands here. D: OK. Im going to send an officer
out there. Slightly edited transcript
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The Call for a CIT Officer (Hindsight 2) PH: And hell 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.
Slightly edited transcript
Slide 14
The Call for a CIT Officer (Hindsight 3) PH: OK. Whats the
procedure? D: Theyll 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 husbands in there
with him, but hes becoming more and more belligerent and um D: OK.
Your husbands in the room with him now? PH: Yes. D: OK. Ill let
them know about this information. PH: OK. Thank you. [End call #2]
Slightly edited transcript
Slide 15
The Call for a CIT Officer (Hindsight 4) (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. Hes
got a drum set in his room. D: OK. Hes 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, theyre almost there. PH: Well, Thank you.
[End call #3] Slightly edited transcript
Slide 16
Record from Officers 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? 15:08:09-12PH: Youre with the police?Officer: Yes.
15:08:12-15(More talk, words not distinct on radio recording.
Recollection was PH: Im glad youre here.) 15:08:15Start of Stop
Stop (both PH and Officer, according to statements) 5 seconds of
scuffle 15:08:20-22Six shots fired. 15:08:23-24Officer:
15:08:25Officer: 224 shots fired So What went wrong?
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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.
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Lessons Learned
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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.
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Lessons for persons at risk of a brain disorder crisis (2) Your
disorder is not your fault. You didnt cause it. You didnt ask for
it. You didnt 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.
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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.
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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. Vulnerability Stress Model for Mental
Illness from Ritsner
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Some Non-Psychiatric Conditions Associated With Psychosis White
et al., American Journal of Psychiatry, 163:3, March 2006 See also:
http://en.wikipedia.org/wiki/Psychotic_disorders#Psychiatric_disorders
Some causes are more treatable than others. Anti-psychotics are not
always the answer.
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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
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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 sub- optimal decisions, despite the best
intentions.
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Elements of a Sample Crisis Plan Credit NAMI Minnesota:
http://www.namihelps.org/Crisis-Booklet-Adults.pdf
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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?
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Flowchart for Deployment of Mobile Crisis Outreach Team
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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
(2)
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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 Further Elements of a Mental
Health Crisis Plan (3)
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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
ones 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 (1)
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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 ones 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
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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
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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. Caregivers (4) There is a potential for escalation,
especially if they resist arrest or otherwise fail to give
sufficient deference to an officers authority. If your loved one is
not diverted from the criminal justice system into appropriate
care: o Protecting your loved ones 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.
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(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. (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 Some Potential
Gotchas for Consumers and Caregivers Know your crisis support
team!
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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 patients right to
choose, but be as informative and persuasive as possible regarding
the most appropriate course of action. Psychiatrists 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)
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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. Hospitals that
Receive Mental Health Patients Note: psychiatric emergencies do not
observe 9-5 working hours or holidays.
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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.
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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 buy- in.
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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 (!)
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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 16-
hour CIT training at the police academy.
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- Call Taker / Dispatcher 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. Police Chief / Police Department (4)
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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
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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
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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
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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
Slide 47
Foster a mentoring / learning atmosphere: Post-action reviews
Compile and disseminate lessons learned Continually update
documented best practices Supplementary training Police Chief /
Police Department (9) - Responding Officer- Call Taker /
Dispatcher
Slide 48
Post-Action Review: CIT International Example Incident Tracking
Form
http://www.citinternational.org/images/stories/CIT/SectionImplementation/Outcomes/TrackFormCITINT.htm
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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 dont 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.
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A Caregivers 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.
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Killing is unnecessary
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Workshop Constructive criticism brief to allow more
participation Your most important item Will edify everyone present
THANK YOU !!! Will improve future presentations THANK YOU !!!