CIT Training for Telecommunicators

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Presented by: Dr. Melissa Graham, SAPD Psychologist …

Presented by: Dr. Melissa Graham, SAPD Psychologist

Jeanie Paradise, Clinical Director Crisis Care Center

Lt. Teri Neal, Director SAPD Communications Unit

Emile Clede, SAPD Communications Training Coordinator

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  • 1. International CIT Conference CIT Training for Telecommunicators 2010 San Antonio Police Department
  • 2. SAPD CIT
    • Signs and Symptoms
    • Common Medications
    • Alternative Tactics
  • 3. Partnership
    • Local Law Enforcement
    • Center for Health Care Services
    • University Hospital System
    • NAMI
    • Other local Mental Health Professionals
  • 4. Partnership
    • Improved Service
    • Effective Jail Diversion
    • Community Commitment
        • Exclusive 24/7 Crisis Care Center
  • 5. Telecommunications Support
    • Dr. Melissa Graham, SAPD Psychologist
    • Jeanie Paradise, Clinical Director Crisis Care Center
    • Lt. Teri Neal, Director SAPD Communications Unit
    • Emile Clede, SAPD Communications Training Coordinator
  • 6. Telecommunications Support
    • All available training and resources directed toward the Officer on the street.
        • Visual Cues
        • Tactics and Control
    • CIT Training for Support Personnel nonexistant.
  • 7. Crisis Intervention Training for the Telecommunicator
  • 8. The Course
    • History
        • Why and How CIT Concept Began
        • How SAPD CIT Course began
        • How CIT for Telecommunicators Began
  • 9. The Course
    • Active Listening Skills
        • Review Basic Telecommunicator Training
        • Apply Techniques to CIT Calls
  • 10. The Course
    • Calming Techniques
        • Empathy, not Sympathy
        • Modeling
        • Calm Voice
        • Reassurance
        • Ease Fear, Assure Safety
        • Allow Ventilation
        • Encourage Communication
  • 11. The Course
    • Level of Communication
        • Be easy for caller to understand and relate to
        • Use words similar to those caller uses
        • Keep it Simple
  • 12. The Course
    • Dealing with Mental Illness
        • Calm
        • Patient
        • Double-check Information
        • Use Caller’s Name
        • Instructions One at a Time
        • Engagement – Keep Trying
  • 13. The Course
    • Methods for Gaining Trust
        • Honesty / Sincerity
        • Be Sure you can Do what you Offer
        • Validate Positive Actions by Caller
  • 14. The Course
    • Other Helpful Techniques
        • Introduce / Re-Introduce
        • Available Support
        • Control your Emotions
            • Do not be afraid to reveal
        • Allow Ventilation
        • Reassure Realistically – Don’t Lie
        • Listen Actively
  • 15. The Course
    • Always Send Cover
        • Size and Age Do Not Matter
        • Adrenalin Strength
        • Cover for Officer, Consumer, Family, Bystanders
        • Contact Local Mental Health Authority
  • 16. The Course
    • Emergency Detention
        • Civil Detention – No Jail
        • To Get Help for the Consumer
        • Access to Humane Care
        • Protect Consumer’s Rights
  • 17. The Course
    • Types of Apprehension
        • Order of Protective Custody
        • Mental Health Warrant
        • Emergency Detention
            • Call Taker as Credible Person
  • 18. Mental Illness An Introduction
  • 19. Mental Illness
    • A General Definition:
        • “ Illness, disease or condition that either substantially impacts a person’s thought, perception of reality, emotional process, judgment, or grossly impairs a person’s behavior, as manifest by recent disturbance behavior.”
  • 20. Mental Illness
    • A Professional Definition:
        • “ Mental illness is diagnosed based on behaviors and thinking as evaluated by a Psychiatrist, Psychologist, Licensed Professional Counselor, Licensed Social Worker, or other qualified professionals using a tool known as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, most commonly called the DSM-IV.” (American Psychiatric Assoc., Updated 1999)
  • 21. “ Insanity” (Legal Term)
    • Insanity is considered “a diminished capacity and inability to tell right from wrong.”
    • This is not a psychological term.
    • The definition varies from state to state. Generally used by the court with regards to an individual’s competency to stand trial.
  • 22. Categories of Mental Illness
    • Mood Disorder
    • Psychosis
    • Personality Disorder
    • Developmental Disorder
  • 23. Mood Disorders
  • 24. Definition of Mood Disorder
    • A type of mental illness demonstrated by disturbances in one’s emotional reactions and feelings.
    • The primary symptom is the extremes of mood.
    • Depression is the most common of the two extremes.
  • 25. Depression
    • Common among many people
    • Most people have experienced some form of depression in their lifetime or had repeated bouts with depression.
    • Depression is a natural reaction to trauma, loss, death or change.
    • Major depression is not just a bad mood or feeling “blue” but a disorder that affects thinking and behavior not caused by any other physical or mental disorder.
  • 26. Depression
    • A major depressive syndrome is defined as a depressed mood or loss of interest, of at least two weeks duration accompanied by associated symptoms such as significant weight loss/gain and difficulty concentrating.
    • Five or more symptoms are generally present during the same two-week period and are represented by a change from previous functioning. Depressed mood or loss of interest must also be included
  • 27. Depression
    • Other symptoms may include:
        • Prolonged feelings of hopelessness or excessive guilt
        • Loss of interest in usual activities
        • Difficulty concentrating or making decisions
        • Low energy or fatigue
        • Changes in activity level
        • An inability to enjoy usual activities
        • Changes in eating habits leading to weight gain or loss
        • Changes in sleeping habits – sleeping more or less; an inability to fall asleep; waking up early and not being able to go back to sleep.
  • 28. Things to Remember
    • Depression is an illness, not a personal weakness.
    • The symptoms of depression are recognizable.
    • Treatment is available.
  • 29. Depression and Suicide
    • The single most common factor in suicidal behavior or death by suicide is that the individual is experiencing depression.
    • Suicidal individuals do not necessarily want to die; they want the pain to stop.
  • 30. Suicide Prevention
    • “ LEAPS”
        • Listen
        • Empathize
        • Ask
        • Paraphrase
        • Summarize
  • 31. Assessing Levels of Danger
    • Symptoms?
    • Nature of current stressor?
    • Method and degree?
    • Prior attempt?
    • Acute vs. chronic?
    • Medical status?
    • Chance for rescue?
    • Social resources?
  • 32. Danger to Self
    • Intent (actions/words)
    • Gross neglect for personal safety
    • Specific Plan (action/words)
    • Plans/means available
  • 33. Danger to Others
    • Intent (actions/words)
    • Specific person identified
    • Agitated, angry, explosive
    • Irrational, impulsive, reckless (intent/actual)
  • 34. Myths about Suicide
    • MYTH: People who talk about suicide won’t commit suicide.
    • MYTH: People who commit suicide are “crazy”.
    • MYTH: Once the person begins to improve, the risk has ended.
    • MYTH: Prior incomplete attempts at suicide means they will never complete.
  • 35. Treatment for Depression
    • A number of non-addictive medications are used in treating depression, if needed. It is recommended that persons taking medications for depression not use alcohol. Alcohol can interact with the medications and increase alcohol’s effects or create problems in reaction time and judgment.
  • 36. Treatment for Depression
    • Many people self-medicate their depression with alcohol or other non-prescribed drugs which may give them temporary relief but tends to only increase the depressive symptoms
    • <<<<<<<<< Graphic Video >>>>>>>>>>>
  • 37. Bipolar Disorder An illness involving Mania (an intense enthusiasm) and depression
  • 38. Bipolar Disorder
    • Previously known as manic-depressive illness, a mental illness involving episodes of serious mania and depression. The person's mood usually swings from overly &quot;high&quot; and/or irritable to sad and hopeless and then back again, possibly with periods of normal mood in between. Periods of abnormal mood and associated physiologic changes last for at least two weeks.
    • Bipolar I and Bipolar II
  • 39. Mania May Include
    • Abnormally high, expansive or irritated mood
    • Inflated self-esteem
    • Decreased need for sleep
    • More talkative than usual
    • Flight of ideas or feeling of thoughts racing
    • Excessive risk taking
  • 40. Bipolar Disorder
    • An individual may quickly swing from the manic phase to the depressed stage.
    • An individual cannot maintain the level of activity normally associated with mania for a long period of time.
  • 41. Treatment for Bipolar Disorder
    • The usual treatment for Bipolar Disorder is lifelong therapy with a mood-stabilizer (either lithium, carbamazepine, or divalproex / valproic acid) often in combination with an antipsychotic medication.
    • Therapy, in conjunction with medication, can be very helpful.
  • 42. Psychosis
  • 43. Psychosis
    • An illness involving a distortion of reality that may be accompanied by delusions and/or hallucinations most commonly seen in persons with Schizophrenia, Bipolar Disorder, Severe Depression or Drug Induced Disorders.
  • 44. Symptoms of Psychosis
    • Hallucinations:
        • In psychosis a person hears, sees, feels, smells, or tastes things that are not really there.
    • Delusions (False Beliefs):
        • It is common for a person to hold a false belief and be so convinced that it is true that no logical argument can change the person’s mind.
  • 45. Psychosis: Emotional Cues
    • Lack of emotional response
    • Extreme or inappropriate sadness
    • Inappropriate emotional reactions
  • 46. Substance/Cognitive Disorders (Incl. drug related disorders)
    • Symptoms include:
        • Major loss of contact with reality.
        • Gross interference with the ability to meet life’s demands.
        • May have possible delusions and hallucinations.
        • Alteration of mood.
        • Defects in perception, language, memory and cognition.
  • 47. Substance Abuse Disorder
    • Prolonged abuse of any drug (alcohol, prescription medications or “street drugs”) will cause chemical dependency or addiction. This has an effect on consciousness and if used long enough or in large doses may cause permanent damage to the central nervous system. This may cause a wide range of psychological reactions that can be classified as disorders.
  • 48. Schizophrenia
    • Consists of a group of psychotic disorders characterized by changes in perception.
    • May cause an over sensitivity to sounds and visions characterized by hallucination and/or impaired disoriented thinking.
  • 49. Distorted Thinking Results In:
    • Poor processing of information
    • Illogical thinking that can result in disorganized and rambling speech, and/or delusions.
  • 50. Changes in Emotion
    • May overreact to situations
    • May display “Flat Affect”
    • It is not defined as a “Split-Personality” or “Psychosis”
  • 51. Post Traumatic Stress Disorder
  • 52. PTSD
    • The person’s response to the event must involve intense fear, helplessness, or horror.
    • The characteristic symptoms resulting from exposure to extreme trauma include the persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of the general responses and increased arousal.
    • The full symptom picture must be present more than one month and the disturbance must cause clinically significant distress or impairment to social, occupational, and other important activities to meet the diagnostic criteria.
  • 53. Characteristics of PTSD
    • The traumatic event can be re-experienced in various ways.
      • The person has recurrent and intrusive recollections of the event, or recurrent and distressing dreams during which the event is replayed.
      • In rare instances the person experiences disassociated states that lasts from a few seconds to several hours or even days during which components of the event are re-lived and the person behaves as though experiencing the event at that moment.
      • Intense psychological distress or physiological activity often occurs when a person is exposed to a trigger that resembles aspects of the original drama.
  • 54. Associated Features
    • The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event.
    • Avoids activities, situations, or people who arouse recollection of the event.
    • The individual may have persistent symptoms of anxiety or increased arousal that were not present before the trauma.
  • 55. Associated Features
    • Individuals with post-traumatic stress disorder may describe painful guilt feelings about surviving when others did not survive, or about what things they had to do to survive.
    • There maybe an increased risk of agoraphobia, panic disorder, obsessive compulsive disorder, social phobia, major depression disorder, somatization disorder, and substance related disorders.
  • 56. Risk Factors for PTSD
    • Individuals who have recently emigrated from areas of considerable social unrest and civil conflict may have elevated rates of post traumatic stress disorder.
    • Individuals who have recently experienced combat stress are also at risk.
    • Risk factors for PTSD following exposure included early separation from parents, individuals who have a childhood history of abuse, neuroticism, preexisting anxiety or depression, and family history of anxiety.
  • 57. Personality Disorders
  • 58. Personality Disorders
    • Many Individuals who are functioning minimally in their lives may display characteristics of what are known as personality disorders
    • Individuals experiencing these disorders show personality traits that are inflexible, maladaptive, or inappropriate for the situation, causing significant problems in their lives.
  • 59. Personality Disorders
    • Those who have personality disorders also have very little insight that they have a problem – believe problems not their fault, but the fault of others, the “system,” or the world at large.
    • These traits are often accompanied by some form of depression and may also be seen in those with chemical dependency problems.
  • 60. Personality Disorders
    • Personality disorders are not usually treated like other mental illnesses
    • Those with personality disorders are taught a variety of communications and coping skills
    • Or they are treated for other problems such as chemical dependency and/or depression.
  • 61. Causes
    • Although the causes may not seem relevant for telecommunicators dealing with these individuals, their backgrounds are significant.
    • It is believed that most personality disorders are caused by a family history, usually beginning at a young age, of:
        • Physical or emotional abuse
        • Lack of structure and responsibility
        • Poor relationship with one or both parents
        • Alcohol or drug abuse in the family
  • 62. Personality Disorders Most Often Encountered by Law Enforcement
  • 63. Paranoid
    • Tendency to interpret actions of others as deliberately threatening or demeaning;
    • Expectations to be used or harmed by others;
    • Perceives slights from other people.
  • 64. Antisocial
    • Most commonly recognized in males
    • A pattern of irresponsible and antisocial behavior diagnosed at or after age 18
    • May have one of more of the following:
        • History of truancy as child or adolescent; may have run away
        • Starts fights
        • Use of weapons
        • Physical abuse of animals or other people
        • Deliberately destroying other’s property
        • Lying
        • Stealing
        • Other illegal behavior
  • 65. Antisocial
    • As adults these people often have trouble with authority and are reluctant or unwilling to conform to society’s expectations of family and work
    • These individuals know that what they are doing is wrong, but do it anyway.
  • 66. Borderline
    • Most commonly recognized in females.
    • May have one or more of the following
        • Unstable and intense personal relationships
        • Impulsiveness with relationships, spending, food, drugs, sex
        • Intense anger or lack of control of anger
        • Recurrent suicidal threats
        • Chronic feelings of emptiness or boredom
        • Feelings of abandonment
  • 67. Treatment
    • People with personality disorders usually will not seek treatment because they don’t think they have a problem.
    • They may end up in the criminal justice system because their disorder may lead them to break laws (theft, hot-checks, fraud, etc.)
    • They often receive treatment for chemical dependency or depression.
  • 68. Developmental Disorders
  • 69. Autism
    • A developmental disorder usually appearing before age three;
    • Characterized by:
        • Impaired non-verbal communication including abnormal speech patterns or loss of speech;
        • Lack of eye contact;
        • A restricted range of interest;
        • Resistance to any kind of change;
        • Obsessive repetitive body movements;
        • Lack of awareness of the existence or feelings of others;
        • Social isolation.
  • 70. Autism
    • Symptoms vary from child to child and can range from mild to severe.
    • Treatment is experimental and few autistic children show significant remission of symptoms.
  • 71. Mental Retardation
    • Significantly sub-average intellectual functioning existing concurrently with deficits in adaptive behavior and originating in the developmental period before age eighteen.
  • 72. Questioning Methods
    • Be patient for a reply
    • Repeat questions as needed
    • Ask short, simple questions using simple language
    • Speak slowly
    • Ask open-ended rather than “yes/no” questions
  • 73. Psychopharmacology Melissa M. Graham, PhD Psychological Services San Antonio Police Department
  • 74. Introduction
    • 56% of the critical incidences involve an individual with Psychiatric diagnoses
    • 15% of the individuals in jail have preexisting Psychiatric diagnoses
    • Psychotropic medications act on mind/behavior
    • All medications have positives and negatives. There are no perfect medications.
    • For many Psychiatric disorders medications control symptoms but are not a cure
  • 75. Four Classes of Psychotropic Medications
    • Anti-psychotics
    • Anti-depressants
    • Mood stabilizers
    • Anti-Anxiety
  • 76. Anti-Psychotic
    • This class of medications is use to treat Schizophrenia and other Psychotic disorders.
    • Symptoms include:
        • Hallucinations
        • Delusions
        • Disorganized Thinking
        • Disorganized Behavior
  • 77. Anti-Psychotic
    • Old Medications
      • Thorazine
      • Haldol
    • Advantages
    • Disadvantages
    • New Medications
      • Risperdol
      • Zyprexa
      • Seroquel
      • Olanzapine
      • Geodon
    • Advantages
    • Disadvantages
  • 78. Most Common Antidepressants
    • Lexapro
    • Sertraline
    • Zoloft
    • Effexor
    • Wellbutrin
    • Cymbalta
    • Paxil
    • Prozac
    • Over the Counter: St Johns Wort
  • 79. Mood Stabilizers
    • Bipolar: Marked by one or more manic and depressive episodes.
    • Common Medications:
        • Tegretol
        • Depakote
        • Lithium
        • Valproic Acid
        • Lamictal
        • Neurontin
        • Topamax
  • 80. Possible Side Effects of Mood Stabilizers
    • Nausea, vomiting, and diarrhea
    • Trembling
    • Increased thirst and increased need to urinate
    • Weight gain in the first few months of use
    • Drowsiness.
    • A metallic taste in the mouth
    • Bed wetting (enuresis)
    • Acne
    • Abnormal kidney function
    • Abnormal function of the thyroid gland
    • Toxicity
  • 81. Anti-Anxiety Medications
    • Anxiety: Symptoms Include
        • Apprehension
        • Feelings of Helplessness
        • Panic
    • Advantages
    • Disadvantages
  • 82. Common Anti-Anxiety Medications
    • Valium
    • Xanax
    • Ativan
    • Buspar
    • Benedryl
  • 83. Potential Side Effects of Anti-Anxiety Medications
    • Drowsiness
    • Impaired coordination
    • Muscular weakness
    • Impaired memory and concentration
    • Some cause dependence after long-term use
  • 84. Old vs. New Medications
    • Why are old medications still used?
    • Why do some patients not take their medications?
        • Side Effects
        • Stigma
        • They Start Feeling Better
    • Patient’s Right to Refuse Medication.
  • 85. Alzheimer's Disease and Related Dementia Syndromes
  • 86. Syndromes In The Dementia Spectrum
    • Alzheimer’s
    • Vascular Dementia
    • Delirium
    • Parkinson’s Disease
    • Subdural Hematoma
    • Depression
  • 87. Alzheimer’s Disease
    • A progressive brain disorder that gradually destroys a person’s memory and ability to learn, reason, make sound judgments, communicate, carry out daily activities.
    • The most common organic mental disorder of older people.
  • 88. Alzheimer’s Disease
    • As Alzheimer’s progresses, individuals may also experience changes in personality/behavior, such as anxiety or suspiciousness, as well as delusions and/or hallucinations.
    • These persons may get lost easily, have poor memory, and become easily agitated.
    • It is estimated that 2 to 3 million Americans are afflicted with Alzheimer’s and over 11,000 die each year.
  • 89. Alzheimer’s Disease
    • Features:
        • Language disturbance
        • Recent memory impairment
        • Impairment of motor activities
        • Recognition
        • Hallucinations/Delusions
        • Slow but progressive onset
  • 90. Alzheimer’s Disease
    • Statistics:
        • An estimated 4.5 million American have AD
        • By 2050 number could reach 11.3-16 million
        • Person with AD will live an average of 8 years or as many as 20 years or more after symptom onset
        • 50% of persons over 85 years of age have AD
        • 70% of people with AD live at home, and 50% of all nursing home residents have AD or related disorder.
  • 91. Alzheimer’s Disease
    • Causes: While scientists know Alzheimer’s Disease involves progressive brain cell failure, they have not yet identified any single reason why cells fail. However, they have identified certain risk factors that increase chances of developing AD:
        • Age
        • Family history
        • Genetics
        • Head injury
        • Heart-Head connection (Cardiovascular)
  • 92. Alzheimer’s Disease
    • Early Stage:
        • Memory loss
        • Personality changes
        • Ability to plan declines
        • Word/Name finding problems
        • Decreased capacity for performing complex tasks
  • 93. Alzheimer’s Disease
    • Middle Stage:
        • Memory loss increases dramatically
        • May be unable to recall current address, phone number, school/college, day of the week, date or season.
        • Need help with activities of daily living – selecting season- or occasion-appropriate clothing.
        • Constant supervision is likely to become necessary
  • 94. Alzheimer’s Disease
    • Late Stage:
        • Independent living skills lost
        • Frequently capacity for recognizable speech is lost
        • Need assistance eating, toileting, and there is a general incontinence of urine.
        • Ability to walk unassisted, to sit without support, to smile, to hold the head up are lost – difficulty swallowing.
        • Reflexes become abnormal - muscles grow rigid.
        • No longer recognize selves or family.
  • 95. Alzheimer’s Disease
    • Currently, there is no cure for Alzheimer’s Disease. However both drug and non-drug treatments may help with both cognitive and behavioral symptoms.
    • A key principle of intervention is redirecting the affected individual’s attention, rather than arguing, disagreeing, or being confrontational.
  • 96. Vascular Dementia
    • Risk Factors:
        • Large vessel strokes
        • Multiple small vessel strokes
        • Cardiovascular illness
        • Hypertension
        • Tobacco use
        • Diabetes
  • 97. Delirium
    • An Acute Confusional State
    • Symptoms:
        • Reduced clarity of the environment
        • Change in mood, cognition, or behavior
        • Develop over short period of time and fluctuates throughout the day
    • Usual causes:
        • Medications
        • Pain
        • Infection
        • Toxic and metabolic disturbance
        • Post surgery
  • 98. Parkinson’s Dementia
    • Features:
        • Memory recall impairment
        • Executive functioning
        • Intact language
        • Motor skills impairment
  • 99. Subdural Hematoma
    • Typically the result of head injury
    • Features:
        • Headache
        • Personality changes
        • Focal changes
    • Onset of features varies
  • 100. Depression
    • Features:
        • Sadness
        • Loss of interest
        • Memory impairment
        • Poor concentration
        • Etc.
  • 101. Dealing with Difficult Callers
    • Most 911 callers are going to be at some level of crisis and this is compounded when the caller has a mental illness.
    • The emotions and stressors of a crisis can cause behaviors and reactions to become unpredictable. These too may be amplified by the presence of a mental illness.
  • 102. Aggression
    • Aggressive behaviors can occur suddenly, with no apparent reason, or can result from a frustrating situation.
    • Whatever the cause, it is necessary to try to understand what is causing the person to become angry or upset.
  • 103. Aggression
    • Don’t respond in kind.
        • The caller is not necessarily angry with you.
        • Be positive and reassuring – speak softly and in a soft tone.
    • Try to identify the immediate cause.
        • Think about what was said or what happened right before the reaction.
    • Shift the focus – a different approach
        • Work around whatever triggered the response
  • 104. Confusion
    • Respond with brief explanation
        • Don’t overwhelm the person with lengthy statements or reasons.
        • Clarify with a simple explanation.
    • Ease the pressure on them - Give them time to think.
  • 105. Unpredictable Situations
    • When dealing with callers who have a mental illness, it is important to remember that they are not acting this way on purpose.
  • 106. Final Role Play
  • 107. Crisis Intervention For the Public Safety Telecommunicator San Antonio Police Department Communications Unit Center for Health Care Services Crisis Services Psychological Services