Mental Illness: A Primer for Telecommunicators

Taken from Public Safety Communications Magazine, March 2012

Written by Kelly M. Sharp, a 911 police/fire/medical dispatcher who has been training dispatchers since 1996. She holds a master's degree in education and is certified as a training officer by APCO International and CJTC.

911. What is your emergency?
My daughter is bipolar and won't go to her room.

911. What is your emergency?
There's a Martian wandering in my backyard, and I need the police to send him back into space.

911. What is your emergency?
Ummm...do you know my son Alex? He lives with me, and he likes goulash.

When an incoming call starts out like that, you sometimes groan and think, "Now what am I supposed to do?" Let's face it: Dealing with the mentally ill can sometimes strain the abilities of even the most experienced calltaker. Sure you can muddle through, and you do it well most of the time. But don't you sometimes wonder why you can say the same thing to two people who are in crisis and each responds differently? Does it really make a difference if they are manic or psychotic? Would it be easier to process the call if you knew how to talk with the mentally ill more effectively?

Taking a call from a person with mental illness doesn't have to be complicated, according to Ellis Amdur, author of Everything on the Line: Calming and De-escalation of Aggressive and Mentally Ill Individuals on the Phone, a Comprehensive Guidebook for Emergency Dispatch (9-1-1) Centers. According to Amdur, most 9-1-1 calls involving mental illness fall into four groups: psychosis, delusional thinking, manic depressive/bipolar and depression. Figuring out which one you're dealing with begins with understanding the difference between diagnoses and symptoms.

WHAT DOES THAT REALLY MEAN
Callers will often say, "My daughter is bipolar" or "My son is psychotic." But that gives you nothing to go on. It's a diagnosis of a disease, not a description of a situation. It's no different from a son calling for an ambulance for his diabetic mother, only to reveal through questioning that her symptoms show she has chest pains.

Just like in a medical call, understanding the symptoms can point you the direction you want to go with the rest of a call. Take a caller who says he's psychotic for example. What does that mean?

Psychosis can show up as hallucinations or delusions, or both at once. Hallucinations are about sensory perception. For someone having hallucinations, what they see, hear, smell or feel is real, and nothing you say can convince them otherwise.

To get an idea of what they're experiencing, Amdur suggests closing your eyes while someone else is talking. Can you still hear them? This is the same thing that happens during an auditory hallucination. Trying to tell the caller no one's there is futile. To them, if they can hear it, you should be able to also. If you can't, you're the one with the problem.

People with delusions are those who come across as living in a world much different from yours. In their world, people believe in brain implants that broadcast secret messages, stalking by the FBI and ongoing burglaries by imaginary Ninjas, and they demand that you accept their reality.

"Once they begin talking about their delusion, there is a kind of a pressure in their speech. They have to tell you what they have to tell you, and they are locked in," Amdur says.

With so many things going on in their heads, how are you supposed to figure out what they want? You have to get past the delusion to reach the person who is calling for help. Simply understanding that this person's reality is much different from yours and accepting that what they see and feel are real to them can speed up that process. Then you need to have patience and use clarity and repetitive persistence to get through to them.

"If you hammer at them,...you won't get good information," Amdur says.

"It's going to be very hard to get them to focus on why they are calling," he admits. These will be the people who call, get frustrated and hang up because they cannot communicate clearly, or who become angry when they feel you don't understand what they are reporting.

Try reassuring them you are there to help keep them safe, and you hear what they are saying. For those who can't stay on topic, Amdur suggests reining them in by reminding them why they called 9-1-1. "Help them get back online," he suggests. For example, acknowledge to that male caller that you understand he's upset about the chip in his head, and then remind him he called about an auto prowl.

Sometimes getting through to someone with psychosis is so frustrating it seems easier to agree with everything they say just to get them off the phone. "The problem with buying into [their delusion] is you are now an authority figure who agrees with them," Amdur says. This can be dangerous because you don't know where the delusion will take them.

Take "Sam" for example. Sam is upset that the neighbor is using spy satellites to listen in on his conversations and has bugged his phones. You have listened to this same story four times today and end up agreeing the neighbor shouldn't be using technology to spy on him. Here's the catch: You, as the authority figure, may have just inadvertently given Sam permission to blow up the neighbor's house to destroy the spy stuff.

Instead, you can acknowledge that Sam is upset with his neighbor and suggest options for how he can address his feelings through talking with the local crisis center or mental health professional. In the first example, you are agreeing with his delusion and his plans to deal with it. In the second, you are acknowledging his feelings and connecting him with someone who can help him.

DISORGANIZED THINKING
Some callers who appear to be delusional are really suffering from disorganized thinking. Often found in dementia patients, those with disabilities and children, disorganized thinking means the person cannot organize the information both inside their head and coming from the world around them. It's not surprising, then, that they can't communicate effectively. What's in their brain doesn't come out in the correct words. These are the callers who simply ramble in answer to the question, "What is your emergency?" But that doesn't mean they don't need you.

Take an elderly disorganized woman for example. She's calling to report that she has been assaulted by her son, who is also her caregiver. She remembers that 9-1-1 is the number to call for help but may not be able to express what kind of help she needs when you answer the line. She knows it's wrong for her son to hit her but has forgotten why it is wrong, so she can't explain her situation.

A disorganized caller could be a developmentally disabled teen reporting a fire, an elderly person who has not eaten in three days or a child who has been abused. They know enough to call 9-1-1, but they may not remember what to say when you answer.

Communicating with a disorganized thinker requires patience and repetitive persistence and often will need police of medical dispatched simply to figure out what's happening. "Until proven otherwise, in my opinion this warrants a welfare check," Amdur says.

EXCITED TO BE HERE
Unlike people with psychosis or disorganized thinking, people showing symptoms of mania are in the same world you are. They're just very excited to be here.

"The manic person generally talks very fast...and can run from one thought to another," Amdur says. "They sound excited, and they can be boisterous and loud."

Someone who is manic is not necessarily violent but can become antagonistic because they're so wound up. This is the person who inadvertently starts a bar fight simply because he's annoying everyone around him. "They don't plan to be aggressive; it just happens due to a lack of impulse control," Admur explains.

It's this lack of control, combined with rapid-fire talking and screaming, that can make communicating with someone in a manic state such a challenge. To get them to focus, Amdur suggests saying, "I really want to hear what you are saying, but you are talking so fast I can't understand you. I need you to slow down."

One of the biggest challenges in dealing with a person having a manic episode is not getting drawn into his conversation. Although a manic person may come across as personable and entertaining, laughing or joking can quickly spin them into aggression if they believe you're making fun of them.

Knowing that you have someone who is showing these symptoms is critical information to relay to responders, but the word mania can mean different things to different people. "Don't say to an officer, 'I think he's manic,'" Amdur cautions. "Instead say, 'he sounds manic' and then describe what that means."

HELPLESS & HOPELESS
The opposite end from mania can be depression. "Depression is not sadness; instead, what we are looking for is expressions of helplessness about their own life, hopelessness that things will ever get better and all-or-nothing statements," Amdur says.

The depressed caller may be the person who is distraught because she told her daughter that the dress she was wearing didn't suit her, and she now believes their relationship is over. She is convinced that because she said something critical, her daughter will hate her forever.

We often envision the depressed person as someone who is actively suicidal or as someone lethargic, lying in bed with the covers up over their head refusing to interact with those around them. But those with depression, especially men, can also be angry and aggressive, demanding people notice them.

So when someone calls and says, "My doctor says I'm depressed," where do you start? Again, deal with the symptoms, not the diagnosis. Is the individual reporting an emergency? Is he or she suicidal? Do they just need someone to talk to? Begin with a suicide assessment to ensure the person and those around them are safe. If the caller is not suicidal, try simply asking why they called. Are they reporting their car was broken into and just letting you know that this depressed them? Do they need a police or medical response, or will a transfer to a crisis line or connection with a mental health professional to discuss coping skills work instead?

When dispatching calls involving symptoms of depression, be sure you explain how that information fits into the call. Never say, "The caller is depressed." Instead, try, "The caller says he suffers from depression and is very argumentative with the calltaker." Sure, it's wordy, but it draws a much clearer picture.

COMPASSIONATE CARE
Communicating with the mentally ill can be frustrating, but your priorities should remain safety and compassion.

"Aside from the danger mentally ill people can present, they are exponentially more likely to be the victim of a crime, and that may be hard for them to communicate," Amdur says.

In other words, the person raving about a green man with purple hair roaming through her kitchen may actually be trying to explain that her home was burglarized while she was walking the dog. She just can't get her brain to connect with what she wants to tell you.

In a perfect world, all calltakers would be able to take advantage of crisis intervention training (CIT) to help them understand how to communicate with the mentally ill. CIT programs provide education on the different aspects of mental illness, community resources and an opportunity to practice new skills. But for those who don't have the luxury of formal education, or designated policies and procedures, sometimes having just a bit of extra knowledge can smooth the process when dealing with someone who needs special care.