October 05, 2007

Mental illness, addiction, arrest

The spin is on in the case of Carol Ann Gotbaum's death while in police custody. What I don't get about the whole thing, is why they took her to a holding cell, and not to the emergency room or the psych ward.

The woman was screaming she was sick, and needed help. Her family members were trying to contact authorities to let them know about her condition:

According to the police report released Thursday, Gotbaum's husband, Noah, called the airport several times that night, trying to reach his wife or the airport police, telling them they didn't know the circumstances involving his wife, whom he described as suicidal.

I understand the urgency of the authorities to remove her from the center of the terminal, but what I don't get is why they didn't take her to a hospital. Watching all the available video, it's easy for a casual observer to see that the woman is disturbed. Police deal with criminals, yes, but unfortunately they are also on the front line in dealing with folks who have severe mental health disturbances in public.

This is something that interests me as part of my concern about the aftermath of the Iraq war. Mental health, addiction, and homelessness are a huge problem for veterans:

76 percent of currently homeless veterans surveyed had an active alcohol, drug or mental health problem, or some combination thereof. Of this total, 49 percent reported an alcohol problem, 40 percent a mental health problem, and 31 percent a drug problem. When the time frame is expanded to a full year, 83 percent of currently homeless veterans reported an alcohol, drug or mental health problem, or some combination thereof. Fifty-eight percent of the homeless veterans surveyed reported an alcohol problem, 46 percent a mental health problem and 40 percent a drug problem.

Often, it's the police who are called in to deal with the mentally ill or addicted homeless. Trying to remove someone who is actively hallucinating or experiencing some other kind of distress, whether ideal or not, is part of their job.

Withdrawal symptoms (emphasis mine):

However, within six to 48 hours after not drinking, hallucinations may develop. These usually are visual hallucinations but they can also involve sounds and smells. They can last for a few hours up to weeks at a time.

Also within this time frame after quitting, convulsions or seizures can occur, which is the point at which alcohol withdrawal can become dangerous, if not medically treated. The symptoms may progress to delirium tremens (DT's) after three to five days without alcohol. The symptoms of DT's include profound confusion, disorientation, hallucinations, hyperactivity, and extreme cardiovascular disturbances .

Once DT's begin, there is no known medical treatment to stop them. Grand mal seizures, heart attacks and stroke can occur during the DT's, all of which can be fatal.

The investigation into Carol Ann Gotbaum's death has just begun, and what really happened may not ever be fully revealed. However this case should be a warning, as the country prepares to deal with part of the aftermath of the Iraq war: the mental health needs and addiction of veterans.

Posted by binky at October 5, 2007 08:53 AM | TrackBack | Posted to Health


Comments

Binky,
You do realize that the addiction statistics you quoted were from 1999, before the Iraq and Afghanistan liberations, right? It's no secret that soldiers can have problem with impulse control disorders, but remember, that may be a genetic tempermant of those who choose to be soldiers. The idea of sitting in a foxhole in the dark and not knowing what direction enemy soldiers are coming from, shooting an enemy without hesitation, or walking down a street to draw the fire of a sniper, these kinds of behaviors don't come naturally to people unless they have a strong orbitofrontal brain that governs instinct. And it is the orbitofrontal brain that activates addictive types of learning, so if fits that the same people capable of surviving by sheer instinct are also capable of addiction.

At some point, if we ask police to diagnose for mental illness, this sends us to a weird legal area. The assumption is that criminal behavior is by its very nature irrational. That is, it's not unusual for a criminal to struggle against police. Yes it's irrational, but since a criminal's already irrational by committing a crime, it fits. If all irrational behavior is driven by mental illness, what does that imply? There is no crime, because all irrationality (and criminality) fits as being a product of mental illness. People wouldn't commit crimes unless they're mentally ill. The irrationality of crime is a rational consequence of mental illness.

But that ignores that crime is the illness of the group/community/nation. If only the reality of the individual is valued without an equal value for the reality of the group, then the prosperous functioning of the group is ignored in favor of focus on its individuals. This ignores the importance of the group to the survival and prospering of its individuals. If an individual is disturbing the functioning of the group, then that individual is the illness of the group, so this mental illness label becomes a circular definition. And denying the harm to the group of mental illness as defined as criminal negates the value of the group.

If you're asking a policeperson or security person to distinguish between bizarre behavior such as hallucination and distinguish between schizophrenic versus alcohol hallucinations, that's a whole heckuvalot to ask. The number of things that can lead to disorientation explode the possibilities to include pretty much any illegal drug and alcohol. Hyperactivity could appear to be the result of stimulants or mania, not to mention ADHD. So if you're asking police to be able to differentially diagnose an alcohol DT, you're asking a whole lot.

It's a tragedy, and if I was with her, telling the cops the danger she was in, I'd be angry about losing her. But that doesn't imply that security is at fault for her being dependant upon alcohol and going through withdrawl as a result of not being able to get another drink. She recklessly almost hit somebody with the PDA she threw, she had the wherewithall to argue with security and then lock her legs so they'd have to drag her. This behavior is typical of people who're fighting cravings and losing, they start arguments with people to give them an excuse to revert to their old behavior. If I had a nickel for every problem gambler who's told me they started fights with their spouse as an excuse to leave and gamble, I'd have a jackpot.

I can't believe I would expect security in that situation to think she's anything other than a disorderly passenger. Everybody has a story, but that doesn't make them everyone else's responsibility.

Posted by: Morris at October 7, 2007 12:03 AM | PERMALINK

No Morris, I didn't take the time to read the article, and just slapped it up there.

/ snark

Given that much of the "data" for recent returning vets hasn't had time to spiral out of control (late onset PTSD, progressive addiction, exhaustion of resources, friends and family to the point of homelessness) that data, which for Viet Nam era and later is about what we have.

I would hope that you wouldn't ask the police to diagnose for mental illness, but I never know what you'll suggest sometimes. Like it or not, however, they get the calls from folks who can't discriminate between "drunk and disorderly" and "florid hallucination."

As for the police, they recognize that they are on the front lines in dealing with people in (mental) crisis. Some have even started programs to deal with it:

Nationwide statistics on deaths in police custody aren't readily available. There is no central government agency that collects them. But earlier this year, the U.S. Justice Department's research agency, the National Institute of Justice, finished a study of 63 police custody deaths involving the use of pepper spray. The data bear out some of Dr. Wecht's claims. African-Americans were the majority of victims. Many of the subjects had some kind of prior medical condition. Additionally, many of the deceased had ingested cocaine or methamphetamine.

"All of these cases involve drugs and disease, drugs and disease combined with the confrontational situations to such a degree that in the writer's mind, they cannot be separated in any convincing manner," according to the study's author.

...

"I think it's really hard for people to comprehend how difficult it is to take someone into custody who doesn't want to be arrested," says Paul Schnell, public information officer for the St. Paul Police department.

Schnell is also in charge of training officers on how to handle situations involving a person exhibiting signs of mental illness. Minnesota Public Radio talked to Schnell a few days before James Cobb died in St. Paul police custody.

Schnell says when officers arrive at a scene, they have to make a quick assessment. They are neither medical doctors nor psychologists. But Schnell says they are trained to judge potential safety risks and use the minimal amount of force necessary to get the person into custody.

"Police regard this, these types of incidents as serious," says Schnell. "And yet at the same time, the question is, is there a reasonable alternative? Would it have been better to have let the person go completely? And not even deal with them."

But some say perhaps the police shouldn't be called in cases where someone is clearly experiencing mental health problems or is high and out of control.

John Trepp, an advocate for people with mental health issues and a member of the Barbara Schneider foundation, named for a mentally ill woman who was shot and killed by Minneapolis officers four years ago. An investigation by the Hennepin County sheriff's office concluded that police acted appropriately given the circumstances. Trepp says police officers shouldn't be the first point of contact with a person is suffering from a breakdown.

"Mental illness is a health problem and should be dealt by health care professionals," says Trepp. "And whenever I raise this people say, oh my god you can't send nurses out, you know nurses are expensive. Well, nurses aren't as expensive as cops."

Trepp and other members of the Barbara Schneider Foundation persuaded the Minneapolis police department to implement a Crisis Intervention Team. Minneapolis police officials say 120 officers have received 40 hours of training on dealing with people experiencing severe mental health problems. There are CIT trained officers available in each precinct. Police officials are not certain if CIT officers were present two weeks ago when Lorenzo Doby died.

Cops don't have to know how to diagnose or treat someone, but given that they get called instead of the ambulance, they are placed in an unfortunate situation. And even if someone called the ambulance, do you see paramedics taking care of this woman? Her problem may have been medical, but usually even on those cases the cops come in to physically move the disturbed person. One of my friends works at a large hospital in a major metropolitan area, and when they gets calls from people about family members having breakdowns that need to be removed, they send a mental health worker, a resident, and cops. When the first two can't talk the person out, they send in the cops [note here for Morris] to take the person to the hospital.

Posted by: binky at October 7, 2007 08:54 AM | PERMALINK

My central point, Binky, was how do you expect police to differentially diagnose irrational behavior? And if you don't, do we take everyone behaving irrationally (arguably, all people committing crimes) to the hospital for an evaluation? Do we just start sending out counselors and nurses with cops all the time, then they consult while someone continues to pose a threat to those around them? When 911 hears shots are fired, should they assume someone's acting irrationally and send in an intern and a counselor, put them in harm's way to determine if force is actually necessary?

Further, you're underestimating the effect of different personalities and career selection. The typical personality type for police is ISTJ, for psychiatrists, psychologists and social workers it's INFP, 75% different. Police are of the Realistic Holland type which is the opposite hexagonal pole to the Social type that's typical for counseling psychologists and social workers. So if you ask counselors to behave similarly to police or vice versa, you're trying to force idealists to be practical, and to force those who look at people as problems to be solved to become people who care more about kindness and relationships than solving problems. You're going to get decreased effectiveness at both tasks.

And I'm glad you brought out that quote to acknowledge that the police in this case did not taser, shoot, or even mace this woman, they did use the least amount of possible force to subdue her.

Posted by: Morris at October 7, 2007 02:39 PM | PERMALINK

Morris, we can talk about the shoulds all you want, but regardless of whether an ISTJ should be in that position, they are, and perhaps doing something to educate an ISTJ might be a step towards preventing unnecessary deaths.

Posted by: binky at October 7, 2007 03:48 PM | PERMALINK

I'm with Binky on this. I really don't see how the dominant personality type that gravitates toward a field is relevant. If job X means you are going to be faced with a certain type of problem repeatedly, you should be trained in how to do that as efficiently and effectively as possible, whether or not that response happens to be the natural one for you as an individual.

Posted by: Armand at October 7, 2007 05:20 PM | PERMALINK

Binky,
What makes you think I'm just talking about shoulds? The fact is, certain personality types are a fit with certain jobs. If you change the job, even if you don't change the job title, you're pushing away people who no longer will be a good fit. You want an example. I could theoretically graduate with a degree in psychology and do paperwork all day. What I mean is, my job title may be psychologist but what I'm actually doing is paperwork, a Conventional job, rather than psychotherapy, a Social job. If my Holland type is actually Conventional, and I got through grad school thriving on papers and theses, that'll be fine. But if I got into grad school as a product of my Social Holland type, I'm not going to fit with paperwork all day.

What this means is that instead of being kind and helping people, the things that energize a Social person, I'm going to be doing paperwork, and getting no energy from it to recharge me. This typically leads to boredom and burnout, I end up doing a lousy job at my paperwork up until the point I quit and find a better fit. This is why career counselors exist; if everybody could do every job equally well and get the same from any of them, there'd be no need of career counselors.

So when you start meshing duties that fit opposing or distant types, you get problems. If these cases are as great a concern as you suggest, why not throw them into first aid training? Shouldn't everyone required to take a first aid class be required to differentiate between a manic episode and hyperactivity, between a drug induced hallucination and a schizophrenic hallucination, between disorientation from vertigo and disorientation from alcohol? After all, someone could die as a result of someone not getting appropriate medical attention.

All in all, I come back to the fact that if someone is hurting or being reckless regarding someone else, the first thing to do is to stop that behavior, and that's what cops do. If a paranoid schizophrenic attacks me, I don't want the cops worrying about whether he's a disorganized or other variety of schizophrenic. That's like requiring my doctor to explain everything to me. They're the ones who are good at their jobs, so let them do their jobs.

This is typical of the lib base, government must be ultimately responsible; if someone gets hurt, it's a failure of someone in government (and you can say as you did in the other thread I'm parroting Limbaugh with the "lib base," but the fact is if you google your site, you, Armand, Baltar, Moon, and Joshua have all used either "conservative base" or "republican base," so your only exposing your hypocrisy). This is a compulsive belief, that someone (in government) must be in control, and I find it exceedinly ironic that you would offer a compulsive belief as evidence for the need to assist someone who ultimately died from the effects of a compulsive disorder.

Posted by: Morris at October 8, 2007 12:40 AM | PERMALINK

Hmmmm - it seems to me that ya'll are having (at least in part) a debate about the effectiveness of government action. If the government isn't acting efficiently or effectively, I'd like it's services and actions improved. Guess I'm crazy (and part of the "lib base") that way, thinking that poor government actions merit some reform.

Posted by: Armand at October 8, 2007 10:47 AM | PERMALINK

Come now, Armand, don't forget reality's liberal bias (etc and so forth, ad nauseum).

p.s. Morris, do tell, how many hits do you get searching for "republican base" and "conservative base?"

Posted by: binky at October 8, 2007 11:09 AM | PERMALINK

Recent data about suicide rates for veterans.

Posted by: binky at November 15, 2007 05:27 PM | PERMALINK

Earlier in this thread we discussed the avisability versus feasibility of training the police to better cope with mental health cases/arrests. It turns out that the LAPD, after a fatal incident with a homeless person, created a special team to deal with mental health related calls. Of course, I had to find out about this through coverage of the Britney Spears commitment.

Posted by: binky at January 31, 2008 12:26 PM | PERMALINK

These "crooks and liars" need to study methodology. The upward trend in suicides from 1990 to 2004 has been extensively within females age 10 to 14, increasing by 75%. However, the number quoted by crooks and liars would account for about 8,000 suicides when the national total is about 30,000, fairly stable over the previous decade and a half. I think they got the pollsters from New Hampshire to do the research.

"While the suicide rate among the general population was 8.9 per 100,000, the level among veterans was between 18.7 and 20.8 per 100,000."

Given that males generally commit suicide at a rate four times that of females, and that about twice as many men join as women, it's pretty much where it should be, at twice the national average.

Posted by: Morris at January 31, 2008 02:11 PM | PERMALINK

Ummm - am I reading this right Mo? Your first paragraph notes a surge of suicides among girls, a seemingly disproportionate one. The you close by noting that men commit suicide about twice as often as women. So ... you expect a proportional increase in suicides among men in line with the jump in suicides among girls?

Not being snarky, I'm just confused as to your point/how that all would fit together.

Posted by: Armand at January 31, 2008 02:54 PM | PERMALINK

And gee, what does any of that have to do with police well-trained to cope with mental patients?

Posted by: binky at January 31, 2008 03:02 PM | PERMALINK

The statistics are misleading. Active duty suicides included only about 120 in 2007. That means that the vast majority of suicide by veterans took place in other veterans, probably in accord with national patterns such that older men are more likely to commit suicide. The intent of the piece is to show what a horrible person George Bush is, how "his" war is killing so many people.

But the statistics used by the oh so credible (formerly of Dan Rather fame) CBS news don't tell people how suicide is much more common among men, how the effect of gender among the military would cancel out the military effect if they knew how to control for the most obvious variable. The rapid increase in suicide rate for that particular age group would have been a good story, one that would be nice to explore in a time when our schools are saving people from the shaming influence of God. Why would girls still be killing themselves? But they didn't tell that story.

And having become immersed in a profession that is enmeshed in organizations that exist for reasons besides effect, I am yet interested in how effective the mental health police will be, and could they please do something about John McCain's outbursts?

Posted by: Morris at January 31, 2008 09:32 PM | PERMALINK
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