I’m a social worker in the New York City public hospital system, and I was on a unit called the mobile crisis team, along with a psychiatrist, nurses, and other social workers and supportive staff.

Essentially, we do two things: The first part of my job involves making house calls to people who have missed their appointments at the hospital. We check up on them and make sure they’re receiving the care they need.

Serious, persistent mental illnesses

Typically, we’re dealing with individuals with serious and persistent mental illnesses like schizophrenia, schizoaffective disorder, bipolar disorder and major depressive disorder.

If they don’t show up to an appointment, that generally means they’ve stopped taking their medication, reverted to a psychotic state or are otherwise not doing well. Those are the most common reasons people miss their appointments, but some people simply don't feel that they need care, that they can manage their mental illness on their own, and, of course, most of the time they're wrong.

Occasionally, there were instances when we would arrive and people were fine. If they're able to coherently express that they’re not interested in our services, we leave them alone, case closed.

When you don't want to call the cops

The second part of the job is taking referrals from people in the community who call us as an alternative to calling the police. So, if somebody was having a psychotic break, they could contact us and we would go out.

We aren’t an emergency service so it’s not like you call us and we're there five minutes later. If we took the call on Monday, we’d go out on Tuesday. It was a seven-day operation, so we would also work Saturdays and Sundays. We would assess the situation and take them in for care if the situation warranted.

I help people with serious mental illnesses reconnect to care, so cops don't hurt them. Image 1.

 

I help people with serious mental illnesses reconnect to care, so cops don't hurt them. Image 2.

 

Stigmatized and
misunderstood

The reason this service exists has to do with the fact that the police don't have much of a humanistic training and are therefore unequipped to respond in this sort of context.

There have already been cases this year, or even this month, of individuals with mental illness being killed by the cops because were acting in a certain way that was misunderstood as belligerent or menacing.

I got into this line of work because I had a prior interest in mental health issues. I went to graduate school for social work and worked in a drop-in center for homeless LGBT youth. What I realized being there was the vast majority of them also had serious mental illness. So again, bipolar, schizophrenia, etc. I found that to be the more interesting aspect of the job, so I ended up applying for a position in the hospital system because I knew I’d be working with mentally ill individuals and I think it's a population that’s unfortunately still stigmatized in our society.

I started the job two years ago, but the strange thing is that I don't remember having to undergo any specific training. In the social work roles that I’ve had, the mantra has always been, “learn by doing.” The best training you can get is immersion and interaction. I would go out with a psychiatrist and a senior social worker. Some teams also have a nurse and a caseworker. I kind of shadowed at first so that I knew what to expect and how to react. Going into it, you pick up pretty quickly how to maneuver the situations that come up.

The police don't have much of a humanistic training and are unequipped to respond in this sort of context. There have been cases, even this month, of individuals with mental illness being killed by the cops because were acting in a certain way that was misunderstood as belligerent or menacing.

 

People in distress

We don’t work with police departments in any formal capacity. When we do assess that somebody is in a psychotic state—and that can be a range of things—we are obligated to remove them from their home and bring them to the hospital for evaluation. In order to do that, we need to call the police to come and assist us. We lack the ability to do that on our own so we do have to work with the police informally.

The problem is we often don't have the resources. There are certain mobile crisis teams that have the authority to remove people from their homes, but it’s always recommended that the police be present because they’re able to bring in EMS in order to assist and transport and all of this other stuff.

We’re there to monitor every interaction that happens between the police and the patient or other citizens. As you go along, you notice that the police tend to take a backseat to you because you’re in the business of people.

We’re used to speaking with people from a place of empathy whereas the police are usually less knowledgeable and therefore less sensitive about these kind of issues. There are no official sitdowns between social workers, psychiatric teams and police, but on an informal level, they look to us in terms of how to handle people in distress.

 I help people with serious mental illnesses reconnect to care, so cops don't hurt them. Image 3.

Are you ok?

In the morning I go into the office. We review the cases that we're gonna go out on for the day and then we set them up, which means preparing a packet of documents that includes information about the person, their contacts, their medical history, their previous hospital stays.

First, we try to get in touch with family members and with any outpatient care that they've received in the past. When we go to the home, we generally prefer to call the client while we're outside, just so that we're not knocking on their door without warning because even something as small as that can trigger an episode for some.

From there, the evaluation process is pretty straightforward. If we’re being called by a patient, they want us to be there. If we’re being called by somebody in the community, it’s because they saw or heard something that was a cause for alarm. With the proper training, that's something you learn to pick up on almost immediately. It's almost a snap judgment, whether this person is fine or needs to be evaluated further at the hospital.

It’s one thing to say, “Get off my property or else,” but once people start issuing highly specific threats like,
“I will kill you in this or that way,” you know it’s going to be a long day.

 

 

I help people with serious mental illnesses reconnect to care, so cops don't hurt them. Image 4.

“I will kill you"

Anything that fits the criteria for psychotic behavior is a sign that someone needs further evaluation. This includes things like being overly irate, being overly anxious, irrational thoughts, incoherent speech, delusions of grandeur, mood swings.

There's a big difference between saying to somebody, "I don't want you here because I'm not interested in your services," and being threatening to people, which happens a lot. It’s one thing to say, “Get off my property or else,” but once people start issuing highly specific threats like, “I will kill you in this or that way,” you know it’s going to be a long day. And I’m not just talking about threatening language—we have to be constantly alert to the threat of physical danger. It's interesting because that kind of stuff happens almost immediately after you arrive so you recognize what you’re dealing with right when you begin to deal with it.

By their own logic, why would they seek help for something that they don’t have?

You're coming with us

Once we decide that the individual needs further treatment we call EMS. When EMS comes, they basically collect some information from us and the client, and offer him or her the option of going willingly: “You can come in the transportation provided or, if you'd like, you can come on your own, but either way, you're coming with us, it's just a matter of how smoothly.” One way or another, we get the individual to go with EMS. The rest of the afternoon is pretty much spent drawing up paperwork to document what exactly happened and when, then setting them up with follow-up care. Even after the visit is over, we try to keep them plugged in to our network of psychiatric providers.

We field between four and five cases a day, but that number varies. I’m on one of the smaller mobile crisis teams in the public hospital system. I know that there are certain teams that can do ten or twelve cases a day.

Not really a set protocol

There is no average type of person who uses our services. It really runs the gamut. Every hospital breaks up into the different jurisdictions within a borough. It spans across an entire spectrum because mental illness is something that affects everybody no matter your race, gender, sexual orientation or walk of life.

Although there are certain signs or symptoms you can look out for, mental illness manifests itself differently in different people.

There’s not really a set protocol for dealing with someone who is schizophrenic versus someone who is depressive or someone who has made multiple suicide attempts. Generally, we try to come prepared with as much medical history as possible but we don’t necessarily always have that knowledge at our disposal going in. It really just depends on what you're presented with at the moment.

Ultimately, I don't know that socioeconomics plays a large part in that aspect of things. You have people who are low-income and others who are affluent, and sometimes they're happy to see you and other times they’re not.

Patience, exit strategies

If we can ascertain that someone is at risk of harming themselves or being harmed by the police, the best thing we can do is stay with the patient until they can be processed. We do this ordinarily unless there is a very imminent risk of danger to ourselves. Obviously, the patient and his or her safety is of highest importance to us, but if for any reason we suspect our lives are in danger, we are obligated to leave and call the police from outside the premises. A lot of the job is common sense. We’re of no use to anyone if we’re compromised.

There are always situations that feel a little dicey, but the staff members who have been doing this for longer know how to anticipate and mediate violence.

For example, we try to engage people in their doorway and not go into the home unless we can quickly identify a clear exit strategy. You grow familiar with residential plans and neighborhood grids. That way, if we need to get out, we can get out immediately.

A hostile force

Police presence adds another layer of complexity to the whole thing. On one hand, the police are there to help keep us safe. On the other hand, a lot of our patients understandably perceive them as a hostile force and are therefore more likely to become uncooperative when they’re around. There’s always a push and pull.

We’re not in the business of policing the police—it’s not our primary concern—but simply knowing that other city officials are observing them provides a level of accountability that might otherwise be absent. They're watching everything we do and we're watching everything they do. We have no obligation to go to bat for them if they pull anything illegal or unethical and vice versa. It’s a system of check and balances.

I help people with serious mental illnesses reconnect to care, so cops don't hurt them. Image 5.

There’s not really a set protocol for dealing with someone who is schizophrenic versus someone who is depressive or someone who has multiple suicide attempts. Mental illness manifests itself differently in different people.

Uninvited

Sometimes people are really happy to see you; other times they’re hurling epithets or, worse, physical objects.

There was one time we responded to a woman who had a substance abuse problem on top of major depressive disorder. She told us when we got there that she’d spent the morning contemplating suicide but that our arrival dissuaded her from it: "It's nice to know that people are checking up on me, that people are looking out for me, that someone cares about my well-being—that if I ever got to the point where I couldn’t help myself, there would be someone there willing to help me." That happens maybe one in ten times. But the reality is, we're basically walking into people's homes uninvited. I don't know that I would personally be too accommodating in that instance either.

The more common situation, of course, is one where we’ve assessed that someone needs help but he or she is unwilling to cooperate. The protocol there is to contact the police and EMS and have them brought in for further evaluation. We're not typically having these people admitted to the hospital for an unspecified or extended stay. The point is to get them in a calm, controlled environment, such as a psychiatric emergency room where they can answer questions.  If they’re evaluated and found to be psychiatrically sound and functional, they're free to go. But if there are any doubts about someone’s current mental state, you never leave them behind, you always get them to a hospital.

Over and over again

We see a lot of the same patients over and over again—it’s about a 10% repeat rate. We call them “frequent flyers.”

There are people that I just kind of know will reemerge every week or other week, like, "Okay, we're going to see Mr. Smith or Mrs. Jones today." The reason for this is that even after people have been evaluated and set up with outpatient care, a lot of them simply do not believe that they have a mental illness.

By their own logic, why would they seek help for something that they don’t have? But the proof is in the pudding, so to speak, which means we’re out there periodically reassessing the situation.

I help people with serious mental illnesses reconnect to care, so cops don't hurt them. Image 6.

If they don’t show up to an appointment, that generally means they’ve stopped taking their medication, reverted to a psychotic state or are otherwise not doing well.

Pushback

There are a lot of scenarios where we’re met with pushback and have to get creative with getting someone out the door.

There was one individual who saw us from a mile away and immediately locked the door. The minute we identified ourselves and explained what we were there for, he got very nervous and shifty, which was probably precipitated by his preexisting mental illness. Needless to say, we had to call the police. It took four hours of the police unsuccessfully trying to communicate with this person through a blow horn before they finally gave up and brought in a SWAT team that broke down the door with a battering ram.

A big show

When you forcibly remove someone from their home or damage their property, there is paperwork upon paperwork, which explains why the cops will spend hours trying to diffuse or de-escalate the situation.

Once the cops are called, it becomes a big show. They’ll send in an entire police force. The more resistant a person becomes, the more people they send in, so it’s not unusual that thirty or forty officers will show up.

There was so much downtime during the negotiations that we actually had the opportunity to hang out with the police and understand where they were coming from— to just talk about things we’ve seen and the experiences we’ve had.

When you forcibly remove someone from their home or damage their property, there is paperwork upon paperwork, which explains why the cops will spend hours trying to diffuse or de-escalate the situation.

Illustrations by Hopes & Fears