For years, clinicians from The Providence Center, a leading provider of mental health and addiction treatment in Rhode Island, have co-responded with Providence police to calls where serious mental illness seems to be involved. Pairs like clinician Rachel Armada and Officer Luis Tavares work to deescalate situations, get folks into treatment where needed, avoid unnecessary arrests, and get everyone home safe.
Rachel Armada
Rachel Armada, a licensed clinical social worker, works full-time for The Providence Center as a co-responding clinician with the Providence Police Department. She works the first shift, 7 a.m. to 3 p.m.
As a clinician embedded with police, what does your day look like?
In the mornings I will choose an officer to ride with for the day. I very strategically ride with different officers in different areas of the city. I may ride with an officer who's in the downtown area of Providence one day, and then the next day I'll go on the East Side. Sometimes officers have other obligations during their day, too, so I choose who is most available.
If the officer I’m riding with stumbles across a mental health call, we’ll respond so I can formally evaluate that person. If another officer across the city needs my assistance I will respond to that call, and the officer I'm with for the day will take me out there.
What are the types of calls where your work comes into play?
There's definitely a range, but basically I'm called to intervene whenever somebody seems to be exhibiting mental health crisis symptoms, so if they are experiencing suicidal ideation, homicidal ideation, or if somebody is experiencing high levels of psychosis.
Who is generally calling these in? Family members? Bystanders?
We see all of it. Sometimes an individual will call 911 and say they're feeling threatened, and then police arrive on scene and realize the threat isn't realistic or logical, it's psychosis-based. And so I may intervene at that time. Other times family members may call 911 and say they are concerned about their family or their friend—they don't seem to be behaving appropriately, or they're talking about ending their life. And then other times it’s people just observing an individual in the community who seems to be suffering from a mental health issue, and they call for police. Sometimes universities end up calling because college students are exhibiting strange behaviors, that kind of stuff.
Once on scene, what is the division of labor between you and the police officer?
Typically, I end up taking lead. If an officer that I'm not riding with is calling me out it's because they've already intervened on the police side of things, they’ve secured the scene in terms of safety. So they’re now referring that specific situation over to me to make a clinical determination on what that person needs in terms of treatment.
If it's the officer I'm riding with and we approach the scene at the same time, I let the officer make the first contact with the individual, and then they either take a step back or they'll stand next to me, depending on how the person's presenting.
How do you approach someone who may be psychotic or suicidal?
I always try what we call “quick rapport building.” I take a soft approach. They don't always feel warmly about police being there so I try to explain my role: “I'm a clinical therapist. I work for The Providence Center. I'm here to just see how you're feeling and see how we're best able to help you.” A lot of times people take well to that, and so from there I begin to assess their mental status—how reality-based are they, are they experiencing hallucinations right now, are they able to engage in an organized, logical conversation with me. I try to get the person's perception of what's going on: “Do you know why police are called here right now, or what's been happening this morning?”
If they're calm and logical and organized, officers will often allow me and that person more space to have a more private conversation. If somebody is suffering from severe symptoms of psychosis I can't have that same privacy because the person's typically acting unpredictable or behaving erratically, which usually is what would've prompted the 911 call to begin with.
What happens next? What are typical outcomes?
It varies depending on the person and how they're presenting. Sometimes police call me out there because they're not sure the person needs a hospital level of care, but they know something's wrong, this person is struggling with some sort of mental health issue. So I will do an assessment and if the person is presenting as safe enough, they're able to maintain safety in the community, not having high levels of psychosis, I may refer them to outpatient treatment, provide them with resources. If I'm able to build a good rapport with that individual I'll follow up with them in the next coming weeks just to see how they're doing, see if there's any other assistance I can provide them with.
Others times people are having more intensified symptoms, whether that's psychosis or suicidality, but they're treatment-seeking and agreeable to go to the hospital. So I'll help coordinate that care with them: “How can we make this more comfortable for you? Can you ride in an ambulance? Would you like me to meet you at the hospital?” And I’ll help triage that care so it's more seamless.
And then other times unfortunately people are presenting with imminent risk to either harm themselves or someone else, whether that's due to psychosis or due to very concrete suicidal ideation. And at that time I have the ability to put them on an involuntary hold and take away their right to refuse treatment at that time.
Is that a situation where the police officer's presence is important, to take someone into custody?
Yeah. The police officer’s presence is extremely helpful in those cases, because even if somebody's been calm the whole way through my process of assessing them, you don't know how they're going to react when I basically inform them, I know you don't want to go to the hospital right now, but unfortunately I've determined you need that level of care. They can become agitated.
There are people who have been hospitalized unwillingly in the past due to mental health issues, and sometimes it's almost like the role flips a little bit, and those people don't want to talk to me. They're scared of my clinical determination. And so a lot of times I'll lean on the officers then. It's like I'm bad cop and they're good cop now.
What if a person is doing something that is theoretically a violation of the law?
Let’s say police have responded for a domestic call. There's people fighting in the home. And then, it turns out one of those individuals is experiencing a significant mental health issue in that moment.
Was there physical violence in the home? Is that an arrestable offense? Yes. But police will call me and as long as I've come to the determination that yes, this behavior was absolutely due to decompensated mental status, that person basically will be able to receive mental health treatment instead of being incarcerated, instead of getting the arrest, instead of being part of the criminal justice system. In the last fiscal year, there were only two people we assessed, myself and the other Providence Center clinician, who ended up being arrested.
I think police in Providence, having worked with us, understand the benefit of that. Putting somebody in a cell block overnight isn't going to fix the overall issue at hand. They might get called to that home again two days later for the same thing. If it's a mental health issue and we can get this person engaged in treatment, that has better outcomes in the long run.
How about substance use? That can make a situation more volatile, can’t it?
It's definitely a part of the assessment, and there are physical symptoms in people who are under the influence, depending on what they're on. I look at whether their speech is slurred, or if their pupils are dilated or pinpoint, or if they're sweating. I will always ask if they've been taking any substances lately, and I preface that with "I know I'm here with police right now, but you won't be in any sort of trouble. I can promise you that. I just need to know for the terms of your treatment."
The barrier in Rhode Island specifically is as clinicians we cannot mandate any psychiatric or substance use treatment if substances are involved. The rationale is that it's not an organic psychiatric issue. If somebody is having issues with substance use and they don't meet criteria for a true psychiatric hospitalization I can try to refer them to a detox treatment if they're willing to do that. If not, I provide them with outpatient substance use resources and I do try to follow up with them and engage them in treatment.
Sometimes a person become very suicidal but they're also very much intoxicated by alcohol, and in those moments if they don't want to go to the hospital, even if they're endorsing to me they are just set on ending their life, I legally cannot sign the paperwork to put them on an involuntary hold. I can, however, tell the officer I'm with that they need to be taken to the hospital in protective custody because they are an imminent threat to themselves right now. I am not leaving them in the community unattended. I will explain to hospital triage staff the situation at hand and why I couldn't legally sign the cert for an involuntary 10-day hold, but they at least need to sober up and be reassessed before being discharged.
Have you been in situations where you think you could have handled the call without police?
I have, but it's not very common, I think because typically when somebody is calling 911 you're looking at a threat to safety. There have been a few occasions where I'm called on scene, the person's calm, the family is calm and helpful, and police really take a backseat, and when it's all said and done I could've probably handled this without them.
At The Providence Center we do have a 24-hour emergency line where people can always speak with a clinician, and from there care is triaged, whether that means somebody going out for an assessment at the home or helping that person navigate resources on their own. So that's available to people in Providence.
At the other end of the spectrum, have you ever felt like a scene was really scary?
There have been times where I have definitely felt more afraid on scene, but even in those moments it was clear that this was a mental health issue.
A couple years ago I was with police and a family had come to the police station. They didn't know who else to go to aside from police. It was a mom. She said her son didn't seem right. She wasn't able to really articulate what that meant, but he thought people were coming after him, so he was paranoid, and she said he had a gun at home.
I went with police. Everything turned out okay. But he had a propped and loaded assault rifle, like ready to shoot, aimed out the window at people who were passing by who he very illogically believed were trying to harm him. I had to wear a ballistic vest on scene.
We've also had situations where I'm trying to tell a person, "I'm worried for your safety. I need you to go to a hospital and speak with a psychiatrist." And their mental status is decompensated enough they're not even really recognizing the situation they're in, and they've lunged towards me and police have intervened then. We've had a few instances where people are feeling suicidal or having psychosis or both, and they are barricaded with large knives.
Most of the time when I’m on scene police do not end up having to go hands-on by any means, and things can go very smoothly.
How many crises do you tend to respond to in a given month?
It varies. I always say you can’t predict a crisis. But it does seem to come in waves, and last month I had 22 full crisis assessments, where people were in imminent mental crisis and required my intervention in the month of November [2021]. I would say typically I'm doing at least 12 a month on average.
Officer Luis Tavares
Officer Luis Tavares, born and raised in Providence, has been with the Providence Police Department for four years. Like Rachel Armada, he works the day shift. He does not work a specific geographic post, but is assigned to areas across the city according to need.
How did you first learn about ride-alongs with civilians? Did it seem strange to you?
No, it was explained to us through the [PPD] training academy. My first experience, I want to say two and a half years ago, was with a clinician who had the position before Rachel [Armada]. When Rachel came on, it just continued, and I was opened up more and more to the ride-along situation. I talk with Rachel while we drive and go to the calls. But we were told in the academy about all the different types of clinicians that we work with, The Providence Center, Day One [a sexual assault and trauma center], Family Service, and so on.
How does your co-response get dispatched to mental health calls?
If it comes over the radio, sometimes they do have some information from whoever's calling, and if it has anything to do with mental health, prior to even being called, depending on where the person is in the city we'll either make our way or Rachel will contact our officer on a different channel and just say, "Hey, if you need me, just give me a call. I'm riding with Officer Tavares." Most officers understand that we do have a clinician. So either they know Rachel's riding with one of us, or they'll come over the air and say, "Hey, yeah, this is a mental health. We may need Rachel to come and evaluate this person."
What’s the value of having a mental health professional on scene?
From information we're getting from a caller or a loved one, you can get an idea that a person's just not where they maybe should be. And as an officer now, you may want to talk to that person and just see what's going on. Most of the time when you do try to speak with somebody, they're not as open; they may not be so welcoming when they see a police officer, and especially a police officer in uniform. When you have somebody like Rachel who's in plain clothes, they tend to open up more. She adds that extra element when a person says something to the effect that he's talking to somebody in the sky, or somebody's talking to him in his mind.
Our main objective is to get everybody the help that they need. With the clinician you have a person who can refer them to the help, whereas a police officer, we're basically there more for safety reasons. There’s only so much we can do.
Do any particular situations come to mind where that clinician presence counted?
We had one situation, I remember I was riding with Rachel. And the call comes in as a middle-aged woman, suicidal, standing on the ledge of a level-five parking garage. We heard it over the radio and we made our way towards there. As we get on scene, you see this woman, from the middle of the street we look up and she's at the ledge of a parking garage. The officers on scene already had the scene controlled and made contact with the woman, they already had a rapport with this woman, and they guided Rachel in.
She was a little more open with Rachel. Rachel was able to get her name. And she would take her hand off the railing, leaning toward the edge, but we noticed that every time Rachel would say her name she would grab onto the railing again. Rachel, along with our police negotiator, talked to the woman for 15, 20 minutes, trying to calm her down. Between the negotiator, Rachel, and the first officer that responded, they did a great job interacting with her. The officer was able to finally come from the stairwell and grab her hand where she was holding on and bring her down. And then we were actually able to get her the help that she needed.
It is an extra duty to protect the clinician? Is that a concern in some situations?
With every situation, as a police officer, that is essentially a first job, just safety for everyone. If we're the first ones on scene, it's just make sure that whoever's involved, whether it's family, friends, roommates, is in an area where it's safe for them, and the subject or the victim is also in a safe area, like away from the kitchen where there's possibly knives, or their room, where we don't know what types of stuff they may or may not have.
Once the scene is secured and we are in an area where we can speak with the person, that's when Rachel comes along and starts speaking with them. And then Rachel does a great job with keeping distance and interacting with the person. If the person was to react a certain way, we'll step in. Every officer on scene understands and knows their tactical positions, where you're going to react or be able to react if necessary.
How do you handle mental health calls where an apparent crime has been committed?
We don't want to be the robot police officer, where we get on scene and go, "We're going to arrest you. You did something wrong." You need to have the backstory. Sometimes with what information we're getting on scene, you start to understand that although this person committed a crime, the reason behind it could be mental health. And if we can get to that first, maybe this person would've never gotten to this point where they're committing a crime.
One case in point, police were called for a gentleman who, the family said, wasn't taking his medication. They were worried about him. And that's a perfect example of trying to nip it in the bud. So if we were able to get there before he left the house, we probably could have gotten him evaluated at home and brought him to the hospital. But police got on scene, he already had left the scene. They looked for him, couldn't find him.
About an hour later, we get a call from the Citizens Bank and also Dunkin' Donuts—the same gentleman, fitting the same description, went in there and damaged two ATMs, fled the scene, damaging multiple vehicles, possibly four or five, jumped on a vehicle, stomped, like booted the windshield and then jumped on top of the vehicle hood. Now police responded, we were able to grab him and arrest him. When they were speaking with him, some of the stuff that he was saying, they felt that this probably was a mental health issue.
They called for Rachel, me and Rachel responded. And as Rachel spoke with the man, it was determined that yes, because of the medication and stuff, he was just not there. He stated to Rachel, if I'm not mistaken, that he felt like he was in a video game, and he was playing the video game. Although a criminal act happened, he damaged property, we all know that it was more because of his mental health and him not taking his medication. So Rachel was able to divert that individual for treatment at that point.
As police officers you can’t force anyone into treatment, but you may play a role in getting someone hospitalized if a clinician certifies it’s necessary. How does that go?
Working with Rachel for so long now, and even the other officers I've seen, we all know, she'll give us a little nod or will say, "Okay." And once we know that the rescue's come, it's like, "Okay, this person has to go." Depending how the interaction is going, we know if this person may go willingly on, or may give us a little bit of a hard time. And we start trying to prep ourselves that if we are going to go hands-on, how we're going to go forward with it without hurting the person or us. And we try our best, we try every type of way. The last resort is always going to be, "Hey, look, at the end of the day, it's either you're going to go willingly or we're going to have to put you on a stretcher."
And if it's a stretcher with handcuffs, it is what it is, but it's for their safety. It's very rare. There’s even been times where we've taken off the handcuffs as soon as we put them on, because they say, "Okay, I'm going to walk down myself." And then as we give them back more power it's like, "Okay, you can walk on your own? Yeah, we'll let you walk on your own."