A mental health crisis should not be a death sentence

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Gov. Tim Walz recently signed a law prohibiting the use of the term “excited delirium” in police training. I am grateful that this canard has been removed from training materials, and hope it will soon be stricken from coroners’ reports as an official cause of death. That is a start, but it is not the solution to extralegal killings by police and emergency responders. We must address and reform the root cause of these deadly, unnecessary situations.

Widely dismissed as pseudoscience, “excited delirium” has been used as a catchall description for a range of unrelated medical symptoms and human behaviors. Sometimes listed as either the cause or a contributing factor when a person died in custody, excited delirium was only invoked after the fact once the person was dead. A person does not catch a case of excited delirium, spin in circles and drop dead. In most fatal cases, multiple officers force the person to the ground, pinning them beneath their weight. The combination of prone restraint and multiple bodies crushing down on a person’s chest increases panic and agitation, restricts the ability to breathe, and causes suffocation. This is positional asphyxia. But excited delirium has been used to exonerate officers while the actual cause of death — what the officers did to the person — remained unacknowledged.

All public safety officers must recognize that a person experiencing altered mental status is not the same as a person refusing to follow orders. Treating emotional and behavioral crises as deliberate resistance or aggression fails the public. This is where the breakdown occurs: police officers issue “lawful orders” and the civilian does not immediately comply. This gets labeled “resisting,” which justifies physical escalation. But the person’s behavior must be recognized and treated as something other than resisting and refusing to comply. It is that simple.

None of us come to work looking to do harm to others. In my 24 years as a Minneapolis firefighter/EMT, I have been on multiple scenes with agitated civilians and incoherent people. That is the essence of emergency response. It is unpredictable and often chaotic. The safety net is tattered. Most cities have only three options to address a 911 call: police, fire and paramedics. We problem solve a vast range of issues that are not in our job descriptions. We should expect to find people with altered mental status whether incoherent, distraught, intoxicated, or in psychological or emotional crises. These are public health emergencies. This is our workplace. As soon as someone fails to respond appropriately, it is incumbent on me to process this information and reconfigure my expectations and my actions. If we do not improve our understanding and change our tactical approach, we will continue to kill innocent people.

For years, police, firefighters and paramedics were warned in training sessions of the telltale signs of excited delirium: the “naked, sweaty guy” impervious to pain and possessed of terrifying strength. We were instructed that these individuals were generally on drugs like PCP and could not be reasoned with. We were told they must be restrained physically for everyone’s safety. Nowhere in our training were we cautioned that restraining someone could be fatal.

Many people who have called 911 for help with a family member suffering a mental or emotional break have witnessed the police arrive and promptly shoot the person in crisis. The standard defense in these police killings is, “They should have done what the officer said. They should have obeyed orders.” That is usually followed by, “It was a split-second decision. The officer feared for his life and that of his partner.” This ignores several key points, including coherence and competence. Additionally, there are often multiple, even contradictory commands shouted by one or more officers, and so an incoherent person is unable to respond appropriately and immediately. The gap between a shouted command and a gunshot is often seconds — not enough time for someone in crisis. Cities pay out in civil cases, but there has not been improved training or regulation to prevent these avoidable deaths. Training police officers better from the start is a strong gesture of reform. Improving their mindset will help, too.

The recent shooting death of Sonya Massey in Springfield, Ill., by a sheriff’s deputy embodies this tragic systemic failure. Massey called 911, reporting she thought there was a prowler near her house. From the beginning of the interaction, the two officers appeared to recognize that she was not fully lucid. Whether in a mental or emotional crisis or under the influence of drugs or alcohol, it should not have mattered. There was no aggression or threat from her. The officers had room to retreat. There was time to talk. But they used no de-escalation, no calming, no patience. As the horrible video shows, Deputy Sean Grayson treated someone in crisis as a threat. He upped the tension and the aggression, then fired not because Massey attacked or even threatened to attack, but because she did not immediately comply with his threats.

Too many interactions become dangerous explicitly due to responders’ unilateral demand for immediate compliance and submission. What if the person does not speak English? Has a brain injury? Is hypoxic or hypoglycemic or in shock? Is under the influence of narcotics? What if it’s my father with Alzheimer’s or someone on the autism spectrum? I have responded to many people with each of these conditions and none of them were lucid or immediately compliant. None of them were deliberately a threat, either. Yelling orders at an incoherent person is a flawed, futile approach. Putting our hands on them — for “safety” and “control” — seldom calms a person in crisis. We escalate and then treat their response as aggression, rather than something we have caused.

There can be a racial component to these situations too, which for too long has been ignored or denied. There can be an immediate and reactive perception of “threat” when responders encounter a nonwhite person. It may be unconscious bias, but the consequences have been deadly. For decades, the excessive mistreatment of Black people by police was concealed by excited delirium and the problematic claim that Black people had a specific medical deficiency that caused sudden deaths — not that police officers escalated the violence. The fact/truth is, the aggression and force by police toward people of different races is not proportionate or equal; more violence is directed against people of color than white people. Sonya Massey is the most recent addition to the long and tragic list of people of color killed by police officers. George Floyd was one as well; he was not even the first I personally responded to. Both Massey and Floyd were clearly in crisis, yet they were treated only as threats.

Paramedics and firefighters/EMTs encounter a vast array of messy humanity in our work. We do not have guns or Tasers. We get skilled at reading a person and recognizing when they are incoherent or in crisis. By not escalating and not conflating altered mental status with deliberate resistance, we limit the situations that go sideways, that go deadly. Many police officers are also great at this.