On a Sunday, in March 2016, a 16-year-old male calls the Alachua County Combined Communications Center (CCC) and tells the 911 telecommunicator that he is walking around an apartment complex (Gainesville, Florida, USA) and planning to kill himself using the M16 rifle he is carrying. He would not remain on the line and hung up. In spite of multiple call-back attempts by CCC, he did not pick up the phone.
When police arrived on scene, he was ordered to drop the gun, which he did but then retrieved it again, and began to retreat into the occupied apartment complex. Fearing the worst, law enforcement opened fire. Within an hour of the call to CCC, the teen was dead; he had been holding a toy replica of the weapon.
Lt. Brandon Kutner, speaking on behalf of the Alachua County Sheriff’s Office, said deputies thought the gun was real. “Deputies gave verbal commands to drop the weapon, which he initially did,” Kutner said, adding “as we tried to establish a rapport with the individual, to try to get him to move away from the weapon, he picked it up, rearmed himself, and started walking toward an occupied apartment complex.”1
A report issued by Alachua County Grand Jury found the shooting death lawful, but likely “avoidable.” Recommendations in the same report included2:
- A call for the state legislature to consider banning the replica guns like the one the youth had.
- Increased training in interacting with the mentally ill.
The second recommendation emphasized something Jim Lanier had long believed necessary at every stage of an incident potentially involving mental health issues.
“We needed to explore what else we could do for the caller, calltakers, and officers,” said Lanier, Technical Services Division Manager, Alachua County Sheriff’s Office. “If you don’t understand what is happening with the caller, you can’t establish the level of assistance necessary to help.”
Crisis Intervention Training
Several years earlier, the Alachua County Sheriff’s Department participated in Crisis Intervention Training (CIT), a national program to improve response and scene safety. All of Alachua County’s CCC telecommunicators are required to take CIT.
The Durham Police Department (North Carolina, USA) established its CIT program in 2007 in answer to an increasing number of 911 calls and incidents involving people exhibiting serious mental illness.
As explained by Lt. Mark Morais, Durham Police Department, Assistant District Uniform Police Commander, CIT puts law enforcement in partnership with mental health and consumer advocacy groups, families, and individuals with a common goal to connect people in a mental health crisis to appropriate services rather than the criminal justice system. A primary objective is decreasing the use of force in law enforcement confrontations.
“Jails are not equipped to handle people with serious mental illness,” said Morais, who was instrumental in integrating two federal grants that helped design the current Mental Health Outreach Program (MHOP) that now exists in Durham. “CIT gives police more options, ways to work with an individual, and de-escalate the incident.”
CIT nationwide is the genesis of training curriculum developed by Memphis (Tennessee, USA) police in 1987 to address public outrage over the fatal shooting of a knife-wielding male with severe mental illness. The “Memphis Model” includes sections covering clinical issues, post-traumatic stress disorder, de-escalation strategies, and lists of community resources.
Morais said community awareness is a focal point of any CIT program. While extensive training, certification, and overall goals are standard, public agencies are encouraged to develop a model that reflects their community. This includes advocacy groups, such as local chapters of the National Alliance on Mental Illness (NAMI); individuals and family members; and mental health care and treatment professionals.
“Partnerships are vital in making this work,” he said. “You have to get a commitment at the start for CIT to be most effective.”
According to the Memphis Model, an emphasis on emergency communications is essential: Emergency dispatchers are a critical link in the CIT program and may include calltakers, dispatchers, and 911 operators. The success of CIT depends on their familiarity with the CIT program, knowledge of how to recognize a CIT call involving a behavioral crisis event, and knowing the appropriate questions to ask in order to ascertain information from the caller that will help the responding CIT Officer. Finally, dispatchers should know how to appropriately dispatch a CIT Officer. Dispatchers should receive training courses (a minimum of 8–16 hours) in CIT and additional advanced in-service training.3
Lanier said CIT training was extremely beneficial for telecommunicators, but he also wanted a program designed specifically for emergency communications personnel that would provide further guidance and tools for effective mental health crisis call management. With the proper training, the 911 telecommunicator has a greater chance to de-escalate the incident and the danger to the caller, bystanders, and public safety responders.
“We needed something to get to the next level of empathy and trust with the caller,” said Lanier, a longtime proponent of the police, fire, and medical protocol systems. “We wanted to put more focus on the behavioral perspective [in a non-visual setting].”
In July 2016, the Alachua County CCC, with the support of Sheriff Sadie Darnell, took the lead even before the receiving Alachua County Grand Jury’s recommendations by initiating a project where each telecommunicator would attend a three-day certification class (Emergency Mental Health Dispatch (EMHD)) that builds on CIT with an emphasis on the 911 telecommunicator. Facilitated by Jim Marshall, Director, 911 Training Institute, the course targets optimal emergency response based on understanding behavioral factors contributing to a mental health crisis.
Marshall said the certification course fills the gap between the initial call and police intervention and disposition.
“We’re providing real-time crisis intervention from the beginning with the intent of getting help for that person,” Marshall said. “[Through the course] dispatchers develop a greater understanding and compassion for people in a mental health crisis.”
The course provides information on 19 conditions that can affect an individual’s mental health, such as schizophrenia and severe depression. The certified dispatchers (EDMH) do not diagnose the behavior or predict outcomes based on known mental health conditions.
“They optimize cooperation using our call-managing objectives,” he said. “We are bringing the same awareness to mental illness, at the same level as science, as the Medical Protocol did for helping people at risk and safeguarding the scene for response.”
Lanier said the course puts dispatchers at ease in calls involving people in mental health crisis situations.
“From my own experience, I know there’s a feeling of helplessness when answering these calls,” said Lanier, who has worked in emergency communications for more than 20 years. “It’s easy to judge the caller, but this training helps the dispatcher look beyond assumptions and at the human being experiencing a crisis. The outcome might not be what we desire, but at least dispatchers have the confidence they did all they could to manage the call.”
The need is there
The case in Florida is not an isolated incident. An estimated 7 percent of police contacts in jurisdictions with 100,000 or more people involve the mentally ill. A three-city study found that 92 percent of patrol officers had at least one encounter with a mentally ill person in crisis in the previous month, and officers averaged six such encounters per month.6
According to NAMI, each year 2 million jail bookings involve a person with mental illness. Approximately 15 percent of men and 30 percent of women in local jails have a serious mental illness, and 1 in 4 people killed in officer-involved shootings had a serious mental illness.7
Surveys have found that a majority of Americans believe that people with mental illness, such as schizophrenia and depression, are more likely to act violently toward someone else and more likely to commit violent crimes. Other research has suggested that the opposite is true.
According to the U.S. Department of Health and Human Services, only 3 percent to 5 percent of violent acts can be attributed to individuals living with a serious mental illness and, in fact, people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.8
Police Priority Dispatch System™ (PPDS®) Protocol 121: Mental Disorder (Behavioral Problems) applies to “any incident involving an individual who appears to lack essential reasoning faculties or exhibits bizarre, possibly mentally related behavior.” Causes for the abnormal behavior include drug abuse and excited delirium.
The EPD would shunt to PPDS Protocol 127: Suicidal Person/Attempted Suicide if and when, during the call, the caller mentions the possibility of suicide. If that does not occur during the call, the EPD would stay with Protocol 121 in cases of abnormal behavior as defined by protocol.
Protocol 121 is split in two, with Key Questions meant for suspect callers and not suspect callers. The questions are similar in both sequences, although their arrangement differs.
A suspect is first asked, “Is anyone else there with you?” If the answer is “yes” and the suspect hands the phone to the other individual present, the EPD transfers to the not suspect sequence of the Protocol. If no one else is present or the caller refuses to hand over the phone, the EPD continues with the suspect line of interrogation.
A non-suspect caller is first asked, “Is s/he violent?” and the second question, “Were weapons involved or mentioned?” Key Questions continue with the EPD gathering information about the suspect (where the person is now and a description). If the caller does not know whether the person who needs help is violent, according to Rule 2, the EPD should “consider the person to be violent.” Post-Dispatch Instruction c directs the 2nd or 3rd party caller, “If it’s safe to do so, observe her/him continuously. (Beware of being attacked.)”
When the caller is in danger, the EPD provides instructions on Protocol C: Caller In Danger (CID) to guide the caller to a safer place. If the caller cannot take the phone with him or her while getting to safety, the EPD instructs the caller to call back from a safe location and instructs the caller to set the phone down without hanging up. If the caller cannot speak freely, nor communicate otherwise, the EPD will stay on the line as long as necessary. If the caller is able to speak freely, the EPD returns to the main interrogation sequence and continues to obtain critical information for the incident.
The CID Protocol may be accessed at any point in the interrogation when circumstances or caller statements indicate that the caller is in immediate danger; however, it is important to note that the CID Protocol should not be used until after dispatch has been initiated. It is essential to first get responders on the way to provide protection and assistance for the caller.
In PPDS, an ECHO determinant was added as a send point on Case Entry for a CALLER IN IMMINENT DANGER discovered at the onset of the call. This early send point allows the EPD to initiate a 100-E-1 response, provide PDI-a, and go immediately to the Caller In Danger Protocol, bypassing the Chief Complaint and addressing the caller’s safety first. “CALLER IN IMMINENT DANGER” is defined as:
“A situation that places the caller in immediate danger of death or serious injury that does not involve a sinking vehicle, vehicle in floodwater, stuck accelerator, ACTIVE ASSAILANT (SHOOTER), bomb found, suspicious package, bomb threat, mental disorder (suspect caller), or suicidal person/attempted suicide (suspect caller).”
Principles of Emergency Medical Dispatch acknowledges the danger to field providers when trying to help patients exhibiting abnormal behaviors and cautions the EMD to carefully attend “to the hazards that can occur in these cases.” Principles further states that, in many cases, police coverage during these situations is standard policy.9
1 Wiener-Bronner D. “Police killed a 16-year-old who had called to say he might kill himself. He was holding a toy gun.” Fusion News. 2016; March 22. http://fusion.net/story/283280/police-shooting-robert-dentmond-florida/ (accessed Jan. 17, 2017).
2 Pyche TJ. “Grand Jury: Robert Dentmond Shooting Lawful, But Avoidable.” WUFT-FM. 2016; Oct. 16. http://www.wuft.org/news/2016/10/06/grand-jury-robert-dentmond-shooting-lawful-but-avoidable/ (accessed Jan. 19, 2017).
3 Dupont R, Cochran S, Pillsbury S. “Crisis Intervention Team Core Elements.” The University of Memphis, School of Urban Affairs and Public Policy. 2007; September. http://cit.memphis.edu/pdf/CoreElements.pdf (accessed Jan. 23, 2017).
4 “Mental Health Basics.” Centers for Disease Control and Prevention. 2013; Oct. 4. https://www.cdc.gov/mentalhealth/basics.htm (accessed Jan. 23, 2017).
5 See note 5.
6 Cordner G. “The Problem of People with Mental Illness.” Center for Problem-Oriented Policing. 2006. http://www.popcenter.org/problems/mental_illness/print/ (accessed Jan. 19, 2017).
7 “Law Enforcement and Mental Health.” National Alliance on Mental Illness. 2015; Oct. 1. https://www.nami.org/Get-Involved/Law-Enforcement-and-Mental-Health (accessed Jan. 23, 2017).
8 “Mental Health Myths and Facts.” U.S. Department of Health and Human Services. https://www.mentalhealth.gov/basics/myths-facts/index.html (accessed Jan. 23, 2017).
9 Clawson J, Dernocoeur K, Murray C. Principles of Emergency Dispatch. Sixth edition. International Academies of Emergency Dispatch; Salt Lake City, Utah. 2015.
The Centers for Disease Control and Prevention (CDC) provides the following definition and statistics regarding mental illness: “collectively all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.”
Depression is the most common type of mental illness, affecting more than 26 percent of the U.S. adult population. It has been estimated that by the year 2020, depression will be the second-leading cause of disability throughout the world, trailing only ischemic heart disease.4
The definition stands in contrast to the CDC definition for mental health: “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”5