We're all stocked up on crazy - Part I

For the third time in my life, I've been sidelined by mental illness. Like many issues, the cause is attributed to the mix of "bio-psycho-social-environmental". I'll have more to say on my own situation in times to come, and on the topic in general in Part II of this series. My writing has dried up over the course of the last few years so I apologize that I'm digging into the 2019 archives on this one and making a re-post. Being it's from that era, realize it's locked in the state things were in seven years ago. In my next post I'll make an effort to describe what's improved, along with what hasn't and what may have actually gotten worse.

[Originally written 2019, published here in 2021 or so]

I have “Major Depressive Disorder, Recurrent Episode,” according to my hospital’s info portal…or at least let’s just say that’s all I have for the purposes of this blog entry.

I’ve been inspired to write this blog by a great write up I read by Wil Wheaton who has been battling things such as that since forever. It’s a great article explaining a lot of what people like us feel. But I’m not linking to it because I want you on my blog and not his. He’s fucking famous, he doesn’t need more followers…so stay here…stay. Plus, I don’t want to talk about how it feels, that’s a dead horse that’s been beaten enough. I want to talk about the system. So here we go…

///Please note I am not a professional of any kind (in fact, I’m an unprofessional) and this article is not intended to convey medical, automotive, career, marital, financial, athletic, piano moving, political, managerial, carpentry, Kung Fu, cooking or baking, HVAC repair, or industrial power electronics advice. Please consult a licensed attorney, interior designer, qualified psychic, experienced mortician or bonded tow truck operator/recovery specialist in making related decisions.///

If you need help with a mental health issue, call the nation-wide hotline 9-8-8, available 24/7 to help you navigate your crisis.

THE GENERAL SCOPE OF THE PROBLEM

Mental illness is a serious problem in America and everywhere else: According to the first result on The Google it costs the United States $193.2 billion in lost earnings per year— slightly less than the GDP of Vietnam, or enough to give a top-tier Viking range and a used 1993 Dodge Stealth Coupe to everyone in metropolitan Los Angeles—according to the National Alliance on Mental Illness.

AN OVERSIMPLIFIED VIEW OF US HEALTHCARE

The US healthcare system, from the bottom to top, bases itself on evidence-based care.

Studies get done, and things that seems repeatably truest in terms of what cause illnesses and what can manage symptoms, or in some cases cure or reduce the severity of illnesses, get money thrown at them: first by government or other funders of institutions like universities to do research, then by pharmaceutical and care development companies to develop products, then by those same companies to run trials and win approval of those products.

The entire public research system is essentially a taxpayer and patient funded diamond mine for medical equipment, pharmaceutical developers, process product designers, and other medical and therapeutic care product and service companies to find raw information materials for brainstorming new products in a high-risk industry that they can then charge exorbitant amounts to an increasingly broke and indebted populace with an increasing mortality rate.

The insurers create the necessary billing codes, then hospitals or healthcare systems establish the practices, policies and begin implementation of those methods for use of the new equipment or the new process, and in the case of pharmaceuticals, determine when and how the medications is to be recommended, dispensed or prescribed and procedures for the management and monitoring of the consumption of those medicines, their effectiveness in the patient and responding to their known side-effects or ones later identified.

Then the class action lawyers sue everybody all the way back up the food chain for malpractice or FTC violations for whatever issues they can think of.

Then the liability insurers in turn pay for those people and involved organizations to not take a hit so the system can stay afloat and continue to enrich the companies and investors.

But enough of my cynicism. That’s not what I really want to write about today; plus that’s my part three and four posts. I want to focus on the whole system but we need a place to start. So lets start with the illnesses themselves.

WHEN GOD FLIPS TO THE MENTAL ISSUES PAGE OF HIS SEARS CATALOG, WHAT ARE HIS OPTIONS?

When, God forbid you get a mental illness, what happened and why? Well nobody really knows…at all. There are all sorts of hypothesis and contradictory ideas, and billions of peer-reviewed published papers by those in the field, but the brain is the black-box that no one can figure out yet for sure.

People spend years getting research and medical degrees, some spending their personal fortunes and others racking up life-long debt, essentially forgoing a decent young adult life to find ways to manage problems with an organ that nobody on this fucking earth understands in the slightest so people like me can live a decent life, or for others a functional life, or for others a life where they don’t hurt people or break things…as much.

But they’re doing what they can. And to some extent a lot is working. So, don’t write off the system and the treatments, and certainly not the treaters by any means.

They’ve gotten pretty good at the taxonomy of this stuff, and so there’s this thing used by medical providers and insurers called the ICD-10 or the International Statistical Classification of Diseases and Related Health Problems, developed by the World Health Organization (WHO, or the guy on first base).

In the area of mental health it’s organized as follows (Please excuse the liberty I’ve taken with the titles)

SOME KIND OF CEREBRAL DISEASE, DYSFUNCTION OR BRAIN INJURY

Something structurally in your brain is fucked up.

USING SHIT YOU’RE NOT SUPPOSED TO

You’re addicted to a substance or practice that’s not conducive to your long-term existence as a healthy human being, and through a long chain of things, you’re giving a bunch of assholes in both near and far off places money so they can then corrupt governments, kill women and children, engage in terrorism, and suppress human rights.

Not to mention you’re wasting a lot of screen time on Fox’s Cops TV show where I’m stuck watching policemen search every inch of your giant GMC Yukon to count, neatly arrange, and sniff little plastic baggies, when I could be watching them do car chases, fight massive drunk guys, serve high risk warrants and engage in shoot outs.

But you either can’t, won’t, or are having difficulty helping it for reasons that are debated hotly in medicine/psychology, sociology, politics, law and religion.

If the substance you’re abusing is alcohol or tobacco you’re feeding all sorts of other industries and politicians and are a tool, but that doesn’t necessarily mean it’s your fault or you’re a bad person. Again, science and medicine don’t have the best answers here, but have better answers than anyone else.

If the substance you’re abusing is a prescription medication, as is the growing number of substance abusers these days, then shame on the idiot who continues to supply it to you, and the good folks at Endo Pharmaceuticals and their "compassionate" industry friends, lobbyists, and unofficial employees who have day jobs as elected officials.

SCHIZOPHRENIA

A complex illness involving delusions of all kinds, beliefs that thoughts are being placed in your head or being taken out, broadcasting of your thoughts, hallucinations involving any of the senses, and paranoia. Your thinking can be disordered, perceptions can be inaccurate, and you can have issues communicating cohesive thought. You are likely not capable of functioning in society, have run up enough ambulance miles to get a blanket upgrade, know how to order from the secret junk food menu at your favorite inpatient care facility, and can beat everyone at poker in your unit.

You are sometimes suspected by those around you of being capable of the typical horrible and heinous crimes that are somehow deemed newsworthy in a time of constitutional crisis and yet somehow within FCC broadcast standards to graphically describe and visually broadcast at the dinner hour, even though you become squeamish watching yourself bleed from a paper-cut.

Or you could just have a few of the items on the menu to varying degrees: be paranoid of everybody, from your family to your care providers, to local police, to the neighbors, the mailman, and your deli manager, your dog, and the dog's veterinarian, every day, every waking minute, and experience hallucinations, and yet smile and be polite when necessary or just not show your discomfort, while secretly hoping to someday be as functional as Elyn Saks.

MOOD STUFF, LIKE BIPOLAR (MANIA & DEPRESSION)

You are sad for a long time, often feeling a lack of energy or motivation or on the opposite end of the spectrum, you feel endless energy, or you alternate between the two.

You sometimes retreat from life, abandon self-care, detach from loved ones, lose interest in things they used to enjoy and sometimes have or entertain suicidal thoughts or forms of self-harm. At an extreme you may pose a risk to others as well, due to these feelings.

The manic people can engage in sometimes massive and risky behavior (which waxes and wanes with their manic or depressed states).

For instance, you could be a sad dentist who has been claiming sickness and been bed ridden for weeks, and one day decide to cash out your nest egg, hire six contractors to quadruple the size of your offices, buy ten patient bays worth of fixtures and furnishings, purchase an excessive amount of dental supplies, and then plan to treat as many as 8 patients at the same time with your staff of three (which includes the receptionist) in your town with a population of 300.

When confronted by your daughters you make unwanted advances and have to be restrained by their husbands until police arrive.

PHOBIAS, ANXIETIES, AND SHIT NOBODY CAN FIGURE OUT

You’re afraid of stuff that most other people aren’t.

Not like your fear of shopping at the local grocery store that has been robbed four times while you’ve been in it with the getaway driver once nearly running you over with his van in the store parking lot.

More like being afraid to touch door handles, shake hands, ride the train, drive a car, use hand dryers (except for those Dyson Air Blades, that shouldn't count as a mental illness), walk on cracks or drink water that has been within five feet of anyone else.

These things bother you and diminish your ability to function, are an enormous time sink and cause troubling emotions. Plus, they piss your immediate others off.

EATING, SLEEPING AND SEXUAL PROBLEMS

You don’t eat enough, you eat too much, you sleep to little or too much, or at odd times or inconsistently. Oh, and you can’t get “it” up.

FUCKED UP PERSONALITY TRAITS, IMPULSES, AND OTHER SEXUAL STUFF THAT HAS NOTHING TO DO WITH CIALIS

You’re either helpless or you behave like an asshole, but it’s for medical reasons.

MENTAL RETARDATION

Issues with your cognitive development.

DEVELOPMENT PROBLEMS

You have issues related to language, visual-spatial skills, and motor coordination which started when you were really young.

PROBLEMS THAT STARTED WAYBACK, YEARS AGO

You were a reckless, impulsive, accident-prone, discipline-lacking kid, and you may have motor and language issues.

THEY HAVE NO FUCKING IDEA

They call this “not otherwise specified” or NOS. Essentially, they have even less a clue about your problems than about everything else they have no clue about. Once they figure out time-travel, medicine may have progressed to the point that they can help you with this, or at least have a productive discussion.

THE PEOPLE WHO HAVE TO DEAL WITH THIS SHIT

There is an entire industry and system designed to help you, keep you and others safe, and in some ways try to live a better life, while making some people richer at the same time (believe it or not, the people getting richer are not your care providers).

In this and the next few blog posts, I go into this system starting from You to what I think is a pretty comprehensive look at every part of the system and type of person there to help you (and those around you) and that you might have to encounter if things ever got bad enough that you needed to take it that far, as well as how (I think?) it works and what caused it to be this way.

Most people don’t have to go this far into the bowels of it, but it’s good to know how bad things can get as, obviously I’m an optimist.

And if you haven't figured it out yet, I'm an American and this is how I believe it currently works within the United States of America, for better or worse.

THE GATEWAYS TO THE SYSTEM

YOU

Getting into the system for receiving mental health care is rather easy, and its the easiest for everybody if you seek out care for the problems before they blossom.

But getting quality care is a bit like a box of chocolates: you never know what you’re going to get, and some may cause gastrointestinal problems, and other unexpected complications.

Additionally, the candy may decide that you need additional candy that is not fully covered by the money in your wallet or your foreseeable near-term income.

But if you need care, you can’t do it yourself and you don’t want to self-diagnose (or let Dr. Phil or Alex Jones do it for you). I don’t care what anybody tells you, if you think there’s a chance you’re having problems your best bet is to seek professional help and get things checked out with all due expedience.

YOUR PRIMARY CARE PHYSICIAN

If you have a primary care physician, provided you can have one and can afford one, this is your first stop. It may be your last stop, depending on the severity of the problem.

Primary Care Physicians (such as Family Medicine practitioners or Internal Medicine practitioners) in many cases can prescribe anxiety and depression medications themselves and offer basic advice to manage the problem. That could be all you need. For many it is.

If things are more severe, they can refer you on to a therapist or psychiatrist for more advanced care.

FOR BROKE AS SHIT POOR PEOPLE IN THE INNER GHETTO OR FOR COLLEGE OR GRADUATE STUDENTS PAYING HUNDREDS OF THOUSANDS OF DOLLARS - THE LOCAL OR CAMPUS CLINIC

If you are one broke motherfucker, then the local public health clinic is your starting point.

Often staffed by clinicians with prescribing power, who may not be doctors but have adequate training for basic problems, they can be your gateway to not only medicinal care, but access to people who can help you with lifestyle, occupational, relationship or environmental issues, as well as counseling or therapy, and help with social problems.

If you’re horribly unfortunate, being you’re broke as shit poor and living in the inner ghetto, you likely have issues with substances and can likely get assistance for your problems.

If you’re a college student, depending on your institution and the health insurance coverage you have, you are likely getting the care in the previous paragraphs with the possible addition of a few medical doctors (general medicine or psychiatrists) and psychologists who couldn’t get hired anywhere else.

You will pay through the ass likely, for any care outside of this clinic, as it is officially your “primary care provider” and if you need advanced care at an actual hospital there will be significant limitations, as you can’t expect institutions with multibillion-dollar endowments to put your need for quality health care over their need for higher pay to institutional leadership, unnecessary building upgrades, paintings, nicer planters, elegant bollards, wrought iron fences for areas no one would try to access in the first place, solid glass bus shelters with 24-hour monitoring and rapid repair service, and expertly masoned brick sidewalks.

Likely you will be limited to around 20 mental health visits per calendar year, according to someone I know currently in college.

A SOCIAL WORKER OR LICENSED MENTAL HEALTH COUNSELOR

The social worker is the enlisted grunt that is the backbone of the mental and social care system in America that is buckling under immense weight. These people are counselors, therapists, case managers, affordable housing advisors, government aid resource experts, child and family safety advocates, disability resource specialists, child development care coordinators, advisors to the court, and a fuck lot else that I can’t even think of. If you suffer from any form of disadvantage in the United States that you alone cannot handle, these people are the ones there to help.

As this is an article on mental health, I must say that some of the best therapists in the world are social workers or their close cousins, licensed mental health counselors. Because they get paid shit and get treated like shit, to do this they really have to have a deep inner desire to help people. Either that or they’re stupid, or have other sources of income. I’ve known both of the first types of people (two I’ve worked with over the last couple of years and months through their direct help, another who is a friend of my wife I highly respect, and a third one who I’ve known all along is just fucking stupid).

CLERGY

This is a very tricky one. When it comes to our personal lives, the advice of clergy can be very helpful in terms of remaining a good ethical person and in maintaining the belief in a higher benevolent power in matters that are largely beyond your control and that can keep you comforted in bad times that you just need to plow through.

On matters of God, or whatever your religion calls him (or her) and living a just life and dealing with hardship with strength, these are the perfect people to go to. In matters of tactical or strategic decision making, their advice is less useful, because that’s just not their strength.

However, I do know there are those guys on TV at 4AM who walk up to flocks of people, touch their forehead as they collapse and claim to have made “cures.” Then, then return two seconds later in a pre-recorded monologue to explain the importance of calling right now to donate money so the Good Lord can heal you and also help him command the demons to come out from the interior furnishings of his Learjet 75.

Now, my church, the Roman Catholic Church, has had issues, to say the least. But I haven’t been asked to contribute to help construct our Bishop’s personal penguin zoo, at least not yet. I’m pretty sure I’d stay away from that, and recommend you do the same if your tele-church tried something similar.

9-1-1

I like history, so here’s an important story of how 911 came to be. In the mid-60s a woman named Kitty Genovese was brutally killed in New York City. About 40 people heard her clear cries for help in a building across the street in the process of her murder and did nothing—at all. It was horrible. And there was massive public outrage when the story hit the press for a long time.

While there have been a large number of attributed causes to this collective stupidity, not having an easily memorable and instinctive number to call to report a major emergency immediately was an important one. The British 9-9-9 had beaten us by years.

So the FCC working with the American Telephone and Telegraph Company came up with 9-1-1. Something hard to forget, quick to dial and hard to misdial on a rotary phone. I think the concept was settled on in the late 60’s under President Johnson.

Given typical American speed and efficiency, by the late 80’s it only worked for 50% of America.

Speed ahead to the era of cell phones and lordy, what a clusterfuck. In 2015, the location pin-pointing abilities of distressed callers really sucked gorilla cock. I’m confident they’re much better now, after reading about a disturbing technical bug reported to the US CERT late this past May.

In most states, calls from your mobile phone go to the Public Safety Access Point managed by a state agency (like the State Police or Highway Patrol). In a place like Massachusetts for instance, if you’re not on a state highway or getting murdered during the call, they’ll transfer your call to an emergency operator in your area for the service you need (police, fire or ambulance). In a few rare cases, you will then get that department’s directory tree, if you can believe that. Then you’re on with the operator. If you have a bit of lucidity to you in your mental health crisis still, please stay on the line and try to communicate. If not, well, they always respond to no-response calls or hang-ups, just without knowing what to be prepared for. But that's dangerous for you and the first responder, so please try to communicate.

THE EMERGENCY TELEPHONE OPERATOR

The 911 operator is typically the first person you speak with in an emergency, if you can’t flag down a patrol car because it’s the end of his shift and he doesn’t see you, as he had a long detail the night before staring at a yellow flashing arrow, his third job as a bouncer just isn’t working out, and his son is still flunking Spanish even though it’s his wife’s first language.

The 911 operator has the perilous job of speaking to people in various states of mind, of any age, education, and background, and has seconds to determine the scope of the situation, the nature of the emergency, and any non-obvious information given in the call due to situations of duress or compromised mental faculty, all the while as he or she relays that to the dispatchers, or to emergency operations managers, in major events.

When you have a mental health emergency, that operator needs to know what kind of danger exists, if any, who you need help from, if you’ve had this kind of problem before, if you take any important medication or, heaven forbid, have taken a whole lot of something you shouldn’t have, what kind of problem you’re having as best you can describe at present as well as any other useful information that needs to be conveyed to the first responders to prepare them technically, mentally and strategically for arrival on the scene.

The operator in recent years has also become a remote responder of sorts, conveying first aid instructions to parents of choking kids, directions for people delivering babies on the side of the interstate, and other rapid-response crisis counseling and safety information, while also directly conveying the entire situation to the people who need to know and telling them where they need to be.

It involves good technical execution (on the part of the phone system and the dispatch software and integrated GIS system) as well as an efficient, concise, detail-oriented, and probing, yet empathetic and to the point operator.

Failures happen. The biggest one on my mind was the Atlanta Olympic Bombing. A 9-1-1 call by the asshole who placed the bomb gave the location of the threat and the time remaining. But the GIS/dispatch software the operator had on-screen did not have “Centennial Olympic Park” or its address in the location registry and as a result there was delay and confusion in getting units to respond to a place that everyone in town knew, before it went off, to facilitate a rapid investigation and swift evacuation, and in the aftermath, of responding, containing, and preparing for follow-on threats/attacks.

Going back to mental health, a person I know, had a pretty shitty experience with 911, as recently as 2008. This person, in a state of mental distress, called 911 from a cellphone while dressed only in pajamas and socks after getting locked out during a nor’easter in temperatures of about 10 F.

The operator did not ask any probing questions, noted his request for a police officer and the correct spoken location, and said they were on the way. After three follow-up calls (each passing through the state’s PSAP and relayed, with a delay, to the local emergency center) and a period of 45 minutes, an ambulance was sent to the wrong side of the wrong end of the street, which he had to “wave over” and confirm was in fact for him.

Lucky for them it was a lanky grad student going mentally haywire with the insight that he needed help and not an angry woodsman polishing his rifle from the confines of a tinted SUV awaiting an ambush.

THE POLICE

The common first intervention with a person with mental illness comes in the form of police action. This person acts out him or herself, a situation involving the police comes up in which officers notice something isn’t right with a person they’re interacting with or this person has enough insight to ask for help directly.

The United States is a union of states, so each state, city, county, regional task force, or organization with the power to have a police agency, sets its own policy and procedures, as well as parameters for the training, certification and retraining and upkeep of their officers, in compliance with state laws and taking into account their resources.

THE BEAT COP

They typical patrolman has ten zillion things on his or her mind when going through his or her day. Why? Because their colleagues have been shot dead reluctantly responding to repeat 911 calls about a missing Frisbee or have been run over by a drunk driver while helping a tire changer in the middle of a well-lit, ten-acre vacant parking lot at 3am.

Again, it’s the United States and weird shit happens and there is a mindset that at the end of any shift they may not come home.

The mentally ill person comes in more flavors than Baskin-Robins cares to produce (currently exceeding 1,300 different ice creams as of this writing).

The only goal of the cop is ensuring public safety, so his or her role in this is to identify if the person is a threat to himself, others, or property, and if so manage that threat as safely and with the least (if any) force possible. And yes, to determine if there is a crime to deal with.

But in the course of doing that they have to watch for signs of sudden danger. Is the person reaching for a weapon? Is their car still in gear and ready to take off dragging me with it? Etc.

And in the process of trying to make a regular and efficient conversation to find out what the fuck is going on in the first place, they have to continually monitor the people and the environment around them, while ascertaining their subjects frame of mind and the veracity of their statements. And also, being reasonably calm and polite so the situation doesn’t escalate, and they don’t look badly on whatever cameras and microphones are around, particularly their own.

If they’re lucky, they can get the guy or girl voluntarily into an ambulance through their skilled talk alone and let the medical professionals deal with the rest. If they’re unlucky they’ve got to work their way up the force continuum (the escalation of the use of force judiciously to end the threat with as minimal harm to the public and officer [first] and the subject [second]) while getting help from their peers.

This is a gross simplification, but in some parts of the US that means: 1. “I’m only going to ask you once…” and next 2. Deploy Taser or OC Spray. In more sophisticated or “smarter” areas of the country there’s a lot more to this.

THE PATROL SERGENT AND THE PATROL SUPERVISOR

In some jurisdictions this is just the person who has been around longest. More experience a lot of times means they’ve seen what works and what doesn’t with people with mental health problems they encounter.

In some places this means they’ve also been given advanced training in active listening and deescalation and are experts in leading the allocation and management of resources available to ease the situation, like people who matter to the subject (family, friends, even clergy if the person is religious) and the best means to implement such people.

AN ADVANCED CAPABILITIES UNIT

Of all the cities in the United States, the Census Bureau reports that New York City contains the highest percentage per capita of assholes in the United States. Sorry, that’s a joke. But a lot of weird shit happens in a city of 8.5 million closely packed humans with bad people skills, and over the many years of its existence it’s had to develop systems to manage that.

One of those systems is the New York City Police Department’s Emergency Service Unit, whose insignia is seen here.

If that truck on the insignia looks like a fire engine from a Three Stooges episode, that’s because that’s how long these guys have been around dealing with weird shit.

When talked about in news media outside of New York, they’re often called a SWAT team (what Los Angeles called a Special Weapons Attack Team in 1967 after riots showed how unprepared they were for unrest. The deputy chief rightly thought an “Attack Team” didn’t seem to fit the definition of police work and the idea of “helping people” and it was changed to “And Tactics”).

But these men and women in NYC do way more than just shoot up better armed bad guys, and how this relates to mental health I’ll get to.

Unlike the corporate definition of “cross-trained” these people really are cross-trained. If there were a PhD in policing these folks would all be tenured professors.

From being experienced patrol officers and detectives selected from the best of the best, they’re then trained in close quarters combat, fast-roping, hostage negotiation, crowd management, surveillance and counter surveillance, managing HAZMAT and NBC situations publicly or discretely, large and dangerous wild-animal control, certified NFPA Firefighter 1, certified EMTs, and trained in vehicle, train, ship and aircraft collision response, building, substructure, and tunnel collapse, confined-space, underwater, construction site and technical rescue, dignitary protection and emergency evacuation planning, as well as being certified Emergency Psychological Service Technicians specializing in managing emotionally disturbed persons in hazardous, amorphous and time constrained situations.

If the natural gas needs to be turned off along all of Fifth Avenue in an emergency before Con Edison can get there or is deterred by a hazard, or a track at Herald Square needs to be de-energized to so they can put in air bags to lift a train off a man who found his new pet rat at rush hour, or if a lion has outgrown his 43rd floor apartment and just hasn’t been getting the attention he needs, it’s the ESU’s job to show up and deal with it.

There’s a saying in New York, “if a person needs help, they call the cops. If the cops need help they call ESU.”

And just like any department, they need to be able to rapidly respond to the active shooter who, after his $90 per plate I-banker’s lunch, melts down after concluding that the barista who didn’t return his hello was meant to be his life partner, or respond to the woman who is threatening to blow up her brownstone because her husband ordered anchovy pizza one too many times.

Oh, and those damned terrorists, both foreign and domestic; they’re still a thing these days despite their absence from media coverage, and likely only to get worse with the trends in our current national polices and some issues in some place that only AFRICOM is horribly worried about.

So, my meandering comes to this: What gets done when there’s a mental health issue at play with numerous people at risk of someone who’s not playing with a full deck?

NYC was the first to call these people EDPs, or Emotionally Disturbed Persons: “those who appear to be mentally ill or temporarily deranged and are conducting themselves in a manner which a police officer reasonably believes is likely to result in serious injury to himself or others.”

They’re also the first to identify such persons explicitly and have a codified standard of response and targeted training to what is a unique interaction with a non-compliant member of the public.

They didn’t do it on their own volition, but likely after a long series of costly fuck-ups (the typical reason for most policy changes in America, like when you see signs up that “Our staff believes everyone is important.”)

The NYPD Patrol Guide says to isolate and contain the subject within the zone of safety (a minimum of 20 feet) until the patrol supervisor and ESU show up, along with an FDNY ambulance and if necessary notify the hostage negotiation and technical response team and the precinct commander/duty captain. If things get really out of hand, the ESU even have an interior boundary police tape just for the police, which says “No Police Entry - Helmet and Heavy Vest Required.” There is no fucking around.

The whole goal of their approach is to “slow it down.” That “slow it down” thing is beaten into every new recruit’s head, department-wide, in dealing with both EDPs and those just in emotional crisis.

But if you’ve gone bat-shit crazy and you’re dangerous, you can’t expect their hard work, costly and intensive training, and lessons learned over the years to result in an always good outcome for you.

In September of 2008 a naked schizophrenic and bipolar man named Iman Morales scaled a fire escape with a fluorescent light tube and was striking officers desperately attempting to bring him into the building to safety. Brooklyn ESU Lt. Michael Pigott was tasked with managing the situation.

In a bad decision, he ordered one of his officers to fire a taser into the disturbed man who was standing about twelve feet off the ground. The man, being captured on a phone camera video by the crowd, which police had not yet had a chance to contain due to the fluidity of the situation, froze instantly and collapsed to the pavement head first, like a Hefty bag full of vegetable soup. The video went viral.

NYPD Internal Affairs is charged with protecting the integrity of the department and the people it polices, and like any other organization with world-wide visibility, a rough history, some guy named Serpico whose movie keeps showing up ever few months on basic cable, and 40,000 diverse and many specialized officers to manage, it has a hard job.

They grilled Pigott hard on his violation of the explicit policy forbidding Tasering subjects when they are on elevated platforms of any kind. It was a horrible mistake he made, and the stress of the situation and the guilt caused Pigott, who had profusely apologized to the man’s family, had just turned 46, had three kids and a wife, to shoot himself dead in his precinct locker room the next day. Double the tragedy.

If my point isn’t clear yet, I’ll say it again: mental health is a difficult problem (from the depressed mother treated by the rural clinic, the human disaster and former manager who still seems to get by and support his family with the help of care from a teaching hospital, to the man roaming the streets with a flamethrower he made after he had to close his muffler shop and whose last interaction with a clinician was forty years ago in an inner-city middle school's guidance department). The issues are unique and individual and all the solutions suck.

Sometimes new ideas are tried, and they don’t work out too well. This one isn’t exactly new but has been around for about 27 years. Oh, and it’s still used.

It’s called the restraint bag, another tool of the ESU to deal with an EDP who is out of control.

Call it the modern “straight-jacket”, just easier to put on and maneuver a person into an ambulance with. It’s ventilated, but when the subject vomits on the vents or the airflow is impeded, and the subject’s head is fully-zipped in, that can be a problem.

People at places like Bellevue Hospital who receive deliveries of these call them “burritos”. And being in the role of patient care they don’t particularly care for them. But again, what can you do. You can’t exactly give these officers lessons on sedative administration (It’s not Kiev). Again, imperfect solutions to hard problems.

I've just spent tons of paragraphs talking about New York City in this article and there's a reason for that. They have the most resources of any city in the US and more cases to learn from than anyone. And they are still struggling like crazy with this problem. Now think about your city, town, or community.

Just appreciate the magnitude of this problem.

DEDICATED MENTAL HEALTH RESPONSE OFFICERS

Smaller jurisdictions with major problems in this area have sent some officers for specialized training as special Mental Health Response Officers. This is a good step in recognizing the problem. John Oliver on HBO’s This Week Tonight, in a program on a similar topic to what I’m talking about here (told much funnier and tastefully that I am delivering it) described how these officers can be sent to people in crisis, in unmarked cars, wearing plain clothes, and diffuse a situation and discretely bring the person into a facility for advanced care. But good training at the beat cop level is a must and most places simply lack the resources to train enough of these specialized officers.

A PARAMEDIC AND EMERGENCY MEDICAL TECHNICIAN

These people are great at helping people with physical problems, performing rescues with their partner firefighters (or in some cities the police as well), and giving basic or advanced life support so they can get you to a place better prepared to help you. But there’s not much in their tool bag that can help you, the mental crisis patient.

Their job is to calm you down as best they can with talk, report on your vitals and condition to the destination ER, deal with complications, like the physical injuries you sustained in fighting those eight bouncers with billy clubs, keep an eye on your gurney straps, and get you to the nearest hospital without crashing the ambulance.

So, if you've had the misfortune of needing to encountering all these people, or just some of the later, and your ride has just begun, we now move on to the hospital's care of the mentally ill.

Oh, I'm sorry it looks like that's all the time we have for today...next time well talk about:

-THE MAZE OF EMERGENCY AND FOLLOW-UP CARE

-THE INSURANCE SYSTEM

-THE PHARMACEUTICAL SYSTEM

-GOVERNMENT'S BROADER ROLE