A model for managing the mentally ill fixated person at major events

Abstract

Objective:

The main risk of serious harm at major public figure gatherings comes not from terrorists or criminal activity but from fixated persons, many of whom have a serious mental illness. This paper reviews a collaborative mental health-police diversionary model for assessing and managing mentally ill individuals who attend major events because of their fixation on a dignitary or some idiosyncratic cause.

Method:

We examine the role of a multidisciplinary fixated threat assessment service during the pre-operational, operational and post-operational phases of major events in Queensland in 2014, including the G20 World Leaders’ Summit. The benefits and challenges of this unique approach are reviewed.

Results:

The royal visit and G20 Finance Ministers’ Meeting presented opportunities for the Queensland Fixated Threat Assessment Centre to develop and refine its approach to assessing and managing the threat posed by fixated persons at such events. Based on this experience, we also developed a typology to assist in the assessment of mentally ill people who present at public figure gatherings. In the week prior to the G20 Summit, six fixated people required hospitalisation for acute psychosis. A further 18 cases were identified during the event, one of whom was an involuntary patient whose leave from hospital was revoked as a consequence of his concerning behaviour at one of the G20 venues. There were no other admissions to hospital during the event, but in the remaining cases, where indicated, follow-up was arranged through the treating mental health service or general practitioner. There were no disruptive incidents involving fixated individuals during the G20.

Conclusion:

This novel diversionary model for assessing and intervening with concerning, fixated persons at major events proved effective in mitigating the risk posed by these individuals. It also highlighted the need for police, security and mental health services to consider the fixated in major event planning, for the safety of the event, the public and vulnerable mentally ill, fixated persons.

Introduction

In 2014, the Australian State of Queensland hosted a number of important international events: the Royal Visit to Brisbane by the Duke and Duchess of Cambridge, the G20 Finance Ministers’ Meeting in Cairns and the G20 World Leaders’ Summit in Brisbane. Such events are a drawcard for people who fixate on prominent figures because of their imagined relationship with the dignitary, or because they perceive this as an opportunity to attract global attention for their cause.

A number of studies have found that in Western nations, lone individuals with intense fixations pose a greater risk of serious harm to public figures than political or religious extremists (Hoffmann et al., 2011; James et al., 2007; Mullen et al., 2009a). Many of these fixated people have major mental disorders, but have either fallen out of care or are not known to health services (James et al., 2010; Mullen et al., 2008, 2009a). While only a fraction of these individuals progress to seriously disruptive and violent behaviours, they present an opportunity for mental health intervention. Diverting mentally disturbed, fixated persons into treatment has been shown to improve health outcomes and lower the risk posed to public officials, the fixated person and other parties (James et al., 2010; Pathé et al., 2015).

The term ‘fixated’ refers to obsessive preoccupation with a person or an idiosyncratic cause, which is pursued to a pathological degree (Fixated Research Group, 2006). While those who fixate on a person are generally stalking celebrities, people who are fixated on a cause or grievance are more often harassing, and occasionally attacking, political figures (Mullen et al., 2009b). The fixated do not commonly make direct threats to their target before they approach or attack, but many do make statements or engage in behaviours which are essentially manifestations of their fixation and disturbed mental state (Hoffmann et al., 2011; James et al., 2008; Meloy et al., 2012; Schoeneman et al., 2011). Examples include disordered correspondence to public office holders, lawsuits against the government and ‘end of tether’ language. A system for identifying these ‘warning behaviours’ in mentally ill fixated individuals, and the provision of effective mental health intervention can prevent their progression to damaging outcomes.

While some fixated persons pose a threat to dignitaries, given the high level of physical protection afforded to public figures at major events, fixated attendees are more likely to create embarrassment, distress and disruption. Of greater concern, however, in these heavily secured and armed environments, the mentally ill person who resists police direction, seeks proximity to public figures and attempts to breach security barriers is highly vulnerable to adverse outcomes, including criminal charges, serious injury or even death.

This group of individuals requires a strategic approach, combining the skill set of police intelligence and specialist mental health services. The Queensland Fixated Threat Assessment Centre (QFTAC) has this capacity. Established in Brisbane in 2013, it is a collaboration between the Intelligence, Counter-Terrorism and Major Events Command of the Queensland Police Service (QPS) and Queensland Health’s Forensic Mental Health Service (QFMHS). It is unique in Australia, having been modelled on the Fixated Threat Assessment Centre (FTAC) in the United Kingdom (Boyce, 2011; James et al., 2010). The fixated threat assessment model is proactive, in that it aims to prevent harmful outcomes through the identification of warning behaviours and the management of mental illness and other risk reduction measures. This is far preferable to attempting the impossible task of predicting which individuals will progress to attack behaviours. QFTAC endeavours to identify individuals whose problematic communications to public office holders pose a threat to themselves or to public safety. The service comprises mental health staff (a part-time senior psychiatrist and clinical psychologist and full time clinical nurse consultant) from the QFMHS, and two senior constables and a sergeant from QPS with oversight from senior police

Since its inception, QFTAC has played a key role in both the planning and operational phases of Queensland’s major events. This paper describes a model for fixated threat assessment services at such events.

The mentally ill at major events

Our experience at major events suggests that mentally ill people may be attracted to public figure gatherings for various reasons. Many of these will not be fixated, or they may have an ephemeral interest in the dignitary, dictated by their particular perceptions at the time. We have grouped the mentally ill at major events into the following broad categories.

The disorganised

This is an acutely psychotic or intoxicated group. They frequently incorporate the attending VIPs and/or police or protective personnel into their distorted belief system. They may be quite chaotic, such that it is difficult to discern any clear motive for their presence at the event, and there is no history of fixated behaviours. One example ¹ was a man with a paranoid illness who believed the pronounced police presence was intended for him, and that the police helicopter was circling overhead with a view to shooting him.

The curious

This is a rather hapless and innocuous group, most of whom are mentally ill or intellectually disabled. They are less overtly ill than the disorganised, and it is generally their negative symptoms and poor social skills that attract them to these events. Discretion is not their forté, and they may make crude approaches to security staff to question them or take photographs. One example was a man with schizophrenia which was well managed by the local mental health service. While waiting on a park bench to meet a friend, he became intrigued by the dignitaries entering and exiting a nearby hotel and requested that police photograph him with one of the world leaders. He was easily discouraged.

The suicidal

People who are seeking a dramatic exit may gravitate to major events because they are armed settings conducive to secondary suicide, or ‘suicide by cop’. One man who wanted to exact revenge on his former employer threatened to disrupt a large awards ceremony so he could ‘go down in a hail of bullets’. On advice from a family member, the man was apprehended by police, loitering on the outskirts of the venue.

The pest

These are attention seekers, who are not dedicated to any particular cause. Personality disorders commonly feature in this group. They are usually known to police, having attracted publicity through their antics at previous events. One such individual, who had a diagnosis of bipolar disorder, told his inpatient nurse he planned to attend the G20 in women’s lingerie. His hypomania required an extended hospital admission, thwarting his G20 performance.

The fixated

Fixated individuals are pursuing personal contact with a public figure because of their assumed relationship, or they are seeking attention or revenge for a highly personal cause. This group is QFTAC’s remit, and the focus of this paper.

This broad typology provides a useful framework for assessing mentally disturbed individuals at public figure gatherings. Sub-types of fixated persons have been described elsewhere (James et al., 2009; MacKenzie et al., 2009). In the fixated typology, it can be difficult to discern fixated motives in the confused and frequently psychotic ‘Chaotic’ group, and in our experience, they are better classified as ‘Disorganised’ according to the above typology.

QFTAC and major event planning

Prior to 2014, QFTAC had limited knowledge of the management of fixated persons in a major event context. QFTAC consulted with its counterpart in the United Kingdom following FTAC’s involvement in key events such as the Papal Visit to the United Kingdom in 2010, and the London Olympic Games in 2012. From these discussions and QFTAC’s experience of the fixated during its routine operations, planning commenced for its first event: the visit to Brisbane, Queensland, in April 2014 by the Duke and Duchess of Cambridge.

The royal visit

QFTAC’s major event model was developed and trialled during the royal visit. The pre-operational phase extended over several months, during which QFTAC collected intelligence on persons with a known fixation on the British Royal Family, as identified by FTAC in London, interstate law enforcement agencies and it’s local QFTAC holdings. Combined police and mental health data and evidence based criteria (Haworth et al., 2013; James et al., 2010) enabled the allocation of these cases to low, moderate or high concern categories. Those assessed as a moderate or high concern received further follow-up. This generally entailed liaising with treating mental health services and developing a management plan to minimise risk to the patient and the event, or personally assessing cases that were not currently under the care of any health service. One such Queensland resident, who was known to British FTAC because of his regular correspondence to royal family members, had disengaged from mental health care 12 months earlier. Our assessment found him to be acutely psychotic, isolated and living in squalor. His concern level was assessed as moderate, reflecting a moderate potential for adverse consequences. This was based on his delusions of having a mutual relationship with the Duke of Cambridge, claims that the Princess Royal was trying to control his mind, and his stated intention to attend the royal event to warn the Duke of treachery within the House of Windsor. His delusions responded to inpatient antipsychotic treatment, and he was reassessed as a low level of concern.

Pre-operational identification of potential concerns and early intervention played an instrumental role in minimising unforeseen events in the operational phase. QFTAC deployed two teams in a field intelligence capacity during the royal visit, each comprising a police officer and a mental health clinician. In all, 14 cases were identified and managed. In the post-operational phase of this event, QFTAC assessed the strengths and limitations of our emergent model, and these findings informed future operations.

G20 events

In mid-2011, it was announced that Australia would host the G20 Summit in 2014. The G20 is the premier forum for global economic and financial cooperation and decision-making for the world’s leading economies. The Department of Prime Minister and Cabinet held overall planning and deliverance responsibilities for the events in Cairns (Finance Ministers’ Meeting, September) and Brisbane (World Leaders’ Summit, November). The Brisbane event would ultimately host a gathering of 35 world and international leaders, 4000 delegates, 3000 world media and 6000 police (Brisbane City Council, 2014). The QPS provided the policing and security response for Queensland based events. The planning taskforce was set up 2 years prior to the G20. The role of QFTAC was to provide timely and accurate intelligence in respect to the identification, assessment and management of fixated persons – not groups – to ensure the safety and security of the G20. QFTAC hoped to achieve this through the diversion of mentally ill fixated persons into mental health care, the most appropriate response and the most effective form of risk reduction.

Specially formulated legislation was introduced for the purpose of policing the G20 meetings, which afforded increased police powers, including restricting and prohibiting certain individuals and items (G20 [Safety and Security] Act 2013).

Pre-operational phase

Collection and assessment

QFTAC liaised with its partner agencies to identify and collect intelligence for any individuals who might be fixated on a G20 delegate or a cause, and who were deemed to have the capacity to travel to Cairns or Brisbane for these events. The most productive response came from countries with existing fixated threat assessment services, who kept such information (i.e. British FTAC), in addition to QFTAC’s local holdings. These cases were allocated to one of three concern categories, as above. For those who were judged to pose a moderate or high concern and who were under the care of a mental health service, QFTAC liaised with their treating service and arrangements were made for clinically indicated treatment and monitoring. QFTAC directly assessed moderate or high concern cases that were not currently in treatment, usually via a home visit. Where required, that person was linked with their local mental health service for management, or other interventions were implemented to reduce risk, such as removal of firearms or police welfare checks. All cases were flagged as ‘Fixated Persons’ on the police database so that QFTAC could be alerted by police to their attendance at any of the event venues.

Education and training

In the months leading up to the event, QFTAC provided awareness and education sessions to the QPS and Queensland Health. These sessions emphasised the potential risks to mentally ill persons at major events and established hospital referral pathways for acutely ill people encountered at venues. Plans were made for general mental health services to be notified by police or QFTAC of any acutely ill, non-fixated persons at these events and to convey them to the appropriate mental health service for assessment. In addition, QFTAC distributed information packages aimed at assisting mental health teams to identify a patient’s fixation and interest in the G20. Mental health teams were encouraged to seek QFTAC advice regarding more comprehensive risk assessment and management in these cases. While not all patients were felt to be at significant risk of approaching or disrupting the G20, it was important for QFTAC to be alerted to these individuals should they present. This improved our capacity to intervene at an earlier stage in the safest and least restrictive manner.

QFTAC provided awareness training to security personnel at hotel venues and to other components of the QPS response, including Commanders, Dignitary Protection Officers and the Joint Intelligence Group. It also delivered further training to forensic mental health clinicians who provided database support to QFTAC during this period.

Operational phase

QFTAC conducted business as usual, dealing with fixated referrals unconnected with the G20, and this also provided a backup ‘hub’ for QFTAC field intelligence teams. Three field teams, each comprising one police intelligence officer and one mental health clinician, were deployed to cover the meeting venue and dignitary accommodation areas. These teams worked 12-hour staggered shifts, commencing the week prior to the G20 event. Police holdings were accessible on portable iPads and mental health holdings were accessed by clinicians, through a portable mental health database. Field intelligence teams identified cases through observations and interactions, and also received referrals through the Joint Intelligence Group based at Police Headquarters. Field team clinicians consulted with the relevant mental health service and, in some cases, private mental health and general practitioners to arrange further assessment and hospital admission where indicated.

Again, QFTAC’s pre-operational preparations helped minimise unanticipated problems during the event itself. More intensive monitoring was provided by local mental health services to fixated patients who were at risk of approaching the event, and six cases required hospitalisation on clinical grounds prior to the G20. During the Summit, 18 mentally ill individuals who attended a designated G20 location were identified as fixated on a particular delegate or a cause. Leave was revoked in one of these cases, and the patient was returned to a mental health facility after he attempted to meet with one of the G20 delegates. In the remaining cases, QFTAC liaised with the relevant mental health service or general practitioner to facilitate appropriate follow up.

Post-operational phase

This phase included debriefing and a post-operational assessment. Where indicated, QFTAC provided more comprehensive risk assessments and risk management recommendations to fixated patients under the care of general mental health services.

Discussion

The G20 was the largest peace time policing and security operation in Australia’s history. To our knowledge, this is the first time that such a joint police-mental health response has been deployed in this context. Queensland will continue to host a range of State, national and international events, including the Commonwealth Games on the Gold Coast in 2018. It will undertake further comprehensive, post-operational assessments following these events, to inform future approaches to event planning and deployment.

The QFTAC major events model has a strong pre-operational emphasis, enabling early identification of concerning fixated persons and intervention where indicated. Much of this can be achieved before physical security and policing measures are in place, preventing harmful outcomes.

In several instances, the presence of QFTAC teams on site during the G20 spared police and hospital resources, particularly unnecessary police escorted transport to psychiatric facilities. Mental health expertise on site facilitated more appropriate interventions for members of the public who police assessed as requiring emergency transfer to hospital. Furthermore, applying G20 legislation to mentally disturbed individuals (e.g. exclusion notices that prohibited their return to the venue) was not an appropriate strategy if the individual’s mental state deprived them of the capacity to appreciate the nature and implications of such an order. One man believed he had an invitation to join one of the world leaders for afternoon tea, but he was barred by security outside the dignitary’s hotel. The exclusion notice he received was meaningless in the face of such an important commitment. These individuals required a mental health solution, and QFTAC teams were able to offer this.

QFTAC provided a coordinating role for mental health services throughout the G20 events, assisting them to recognise patients of concern and implement suitable strategies to reduce the associated risks, especially to themselves. QFTAC field teams delivered prompt and flexible assessment of patients who were often known to mental health services, and liaised with these services regarding intervention options. QFTAC proved to be a useful resource to police and security operations during the event, assisting with assessments on individuals identified by these frontline staff. QFTAC was also able to develop collaborative, ‘real time’ feedback from its assessments, enabling more informed decision-making by police in the G20 Command Centre.

There were a number of challenges and limitations to this model. First, the identification of fixated persons ahead of the event relies on good intelligence. The FTAC model is a relatively new innovation, and very few police and protective intelligence services keep data on fixated persons. As a consequence, QFTAC had little knowledge of potentially concerning fixated subjects outside Queensland, with the exception of the United Kingdom. Second, field assessments are reliant on mental health and police information. Some mental health information is able to be shared with police according to a Memorandum of Understanding between QPS and Queensland Health, but there were occasional difficulties accessing this database in the field, and information had to be relayed via the QFTAC office at Police Headquarters. Furthermore, while QFTAC can make recommendations to mental health services, the treating teams are under no obligation to follow QFTAC’s advice. One such example was a psychotic woman who travelled 500 km to attend the G20 because of a peculiar grievance; her inpatient team planned to discharge her in the days leading up to the G20 event, still psychotic and still determined to draw attention to her cause. Of particular concern was the decision to discharge her to a hostel near the G20 venue rather than returning her to her home town, because she insisted on staying in Brisbane for the event. Further discussion with the mental health team emphasised the delusional basis for her current choices, and she ultimately remained in hospital until her mental state stabilised, long after the conclusion of the G20.

QFTAC was at risk of becoming a proxy emergency response service for all mentally ill people at the G20, potentially restricting our capacity to respond to fixated persons. This was largely circumvented by our initial screening processes, and education of police and mental health services. It was recognised, however, that fixation can only be discerned in some individuals who are behaving in an odd or inappropriate manner by engaging the person and assessing their motivation for attending.

The capacity for false negatives in field team assessments is acknowledged, particularly where there is limited police and mental health information. QFTAC staff have specialist skills in the evaluation of the fixated, particularly the factors associated with risk for violence, persistence, disruption and escalation, which minimises uncertainty and unmet security needs. False positives – where we have overestimated the risk posed by the individual – is less of a concern in that diversion to mental health care is based on mental health needs, not risk alone.

It is important for all psychiatrists to be aware of the challenge to mental health service provision in these situations and the collaborative approaches that can be taken in these as well as other settings. Major events have provided an opportunity to further develop joint capacity between health and police agencies in Queensland, in the interests of improving public safety and health. QFTAC’s involvement in these events has enabled refinement of our screening tools and identification processes for police and security staff, as well as the risk assessment measures used by QFTAC and its referrers. Through the experience gleaned from these events, QFTAC is better positioned to offer specialised advice to our public figure stakeholders and to law enforcement agencies interstate and internationally. The QFTAC approach to major events is an evolving model that will be shaped by the nature of future events, the participating delegates, education and resources. Fixated, mentally disordered individuals are particularly vulnerable in major event settings and should not be overlooked in event planning. The risk they pose to the security of these events, and primarily to their own safety and that of the general public, requires a collaborative response that draws upon a shared intelligence model.