Well, It's A Start! (Dealing with the Mad and the Reality Challenged)

[Jocelyn]

There are public mental health teams in many areas whose job it is to identify mentally ill individuals who are in need of services including treatment, residential placement, access to benefits, etc.  I assume this is the type of program Yarnspinner's supervisor has called, and if so then it is entirely within their purview and they are both trained and equipped for the needs of the library patrons she describes (though of course some may still decline the assistance).  It's not as if he opened up a phone book and called up the first therapist he saw (I do hope).

As a former community mental health center therapist, this issue came up. It would be highly unethical to approach a person in public and suggest that they need mental health services. We could not do this unless the person was actively dangerous to himself or others. Just striking up a conversation with someone in public could be considered a breach of HIPAA, because one's identity as a mental health therapist could be well known to others in the community, so the very fact that in the middle of my workday I am sitting around having a conversation in the library might permit others to conclude that I was in the process of assessing a person I believed to be mentally ill.

The programs I am speaking of are not community mental health centers, but rather programs that are specifically designed and intended to meet the needs of transient/homeless mentally ill persons, or persons in need of significant support to access public services in the first place (such as, for example, a therapist at a community mental health center). The programs I am familiar with generally function under the term "case management", but I believe the terminology varies. It does not seem as though your experience is the same as the type of support I am describing.

It really doesn't make a difference as to which agency is doing the job- whether it's case managers or therapists. While HIPAA may not apply, there's still the right to self-determination, the right to privacy, and the right to confidentiality, which certain can be breached by going up to people in public and starting to provide professional services except in an emergency. 

[CuriousParty]

There are public mental health teams in many areas whose job it is to identify mentally ill individuals who are in need of services including treatment, residential placement, access to benefits, etc.  I assume this is the type of program Yarnspinner's supervisor has called, and if so then it is entirely within their purview and they are both trained and equipped for the needs of the library patrons she describes (though of course some may still decline the assistance).  It's not as if he opened up a phone book and called up the first therapist he saw (I do hope).

As a former community mental health center therapist, this issue came up. It would be highly unethical to approach a person in public and suggest that they need mental health services. We could not do this unless the person was actively dangerous to himself or others. Just striking up a conversation with someone in public could be considered a breach of HIPAA, because one's identity as a mental health therapist could be well known to others in the community, so the very fact that in the middle of my workday I am sitting around having a conversation in the library might permit others to conclude that I was in the process of assessing a person I believed to be mentally ill.

The programs I am speaking of are not community mental health centers, but rather programs that are specifically designed and intended to meet the needs of transient/homeless mentally ill persons, or persons in need of significant support to access public services in the first place (such as, for example, a therapist at a community mental health center). The programs I am familiar with generally function under the term "case management", but I believe the terminology varies. It does not seem as though your experience is the same as the type of support I am describing.

It really doesn't make a difference as to which agency is doing the job- whether it's case managers or therapists. While HIPAA may not apply, there's still the right to self-determination, the right to privacy, and the right to confidentiality, which certain can be breached by going up to people in public and starting to provide professional services except in an emergency.

Jocelyn, we seem to have different experiences and different perspectives, which are clearly reflected in our responses.

It is not my understanding that anyone is planning to wander up to patrons and start providing professional services in the way you describe, but rather that a team of appropriately trained individuals will be able to assist both the library staff and their patrons. Based on my experience, I can see how that could happen in a way that is respectful of the individuals involved and compliant with relevant laws and ethics. It sounds as though your experience leads you to believe that such a thing is not possible.

Perhaps one or both of us are mistaken. I am sure the OP will clarify when she can.

[snappylt]

Then I read your brief post about how you are shocked that a mental health professional would help, and I don't understand.  Could you please gently explain and help me understand what is shocking about this?

Thank you!

First- I'm a psychiatric social worker by training, and worked in community mental health for about 10 years. (currently I teach).
Mentally ill people have the same rights to privacy and confidentiality as anyone else. They have the right to refuse treatment. These rights are overriden only when the person is dangerous to himself or others.  In that case, the library should call 911 and the cops can notify the mental health center crisis worker to meet them at the library, if they need help (for example, if the person is on a ledge). But we had a stout rule that the cops were to secure the situation before we went in- that was after I responded on a call and the mentally ill person had over a dozen loaded guns. Our rule was that the cops were to transport the person to either the hospital or the jail, and we would respond and assess there.
I would seriously doubt that a mental status exam could be done in a library without violating HIPAA. If a person isn't dangerous to themselves or others, they have a legal right to be as mentally ill, and as loud and inappropriate, as they care to be in a public place, until they commit some other crime, when they can be taken into custody and a judge can rule on whether they are legally competent or whether they should be committed for assessment and/or treatment.
Now, it sounds like most of the patrons are going to conclude that there is something wrong with these people- but as a therapist, my presence sort of confirms the diagnosis. By even responding, I'm confirming that I have reason to believe this person is mentally ill- I wouldn't have left my office and come to the library if I didn't.
It's easy to say that a hallucinating psychotic person needs someone to step in and take control...but there's a slippery slope here. Suppose someone is having a bad day, and they yell at the library staff. Should they have to submit to a mental status exam because they might be mentally ill?  Think about all the Special Snowflakes we talk about here...some of them seem a little questionable to me, but where do we stop?  How about with state hospitals, where people were admitted with 'life sentences' because their families were embarrassed by their conduct? Or in the 19th century, when men could have their wives admitted for being poor housekeepers...since obviously any woman who didn't love to cook and clean had to be mentally ill? And how many dictatorships have admitted political dissidents to mental hospitals to silence them?

We had this exact situation (well, it was a fast food restaurant) happen when I was in practice. The CEO was furious that the psychologist on call hadn't responded, and threatened to fire her. He sent out a memo stating that we would go anywhere and assess anyone. He was stunned when the clinical director and assistant clinical director went to his office and told him that if he were serious, they were going back to their offices to prepare their letters of resignation.

I am not sure of the profession of the person who agreed to this...but my reading of the Code of Ethics for social workers is such that you could be brought up on legal charges and lose your license for going up to people who are not endangering anyone, and starting to do a mental status exam in full view of others.

I hope this makes it clearer.

Thank you!  It does!

I still feel badly for the librarians and their rational patrons - but I can see your point of view now, too.  Thank you for explaining.

[GSNW]

Not having training in library running or assisting people with severe mental health issues, I imagine something like the following:

Library Patron, to Librarian:  Hi, I need a book on karate, also, I need you to watch the door for me because I am (name of heroine) and the bad guys are after me.  They are out to get me, because (goes into long explanation)...
Librarian:  I can help you find the book you are requesting. 
Patron:  But the guys are coming, I might have to fight them and...
Librarian:  Patron, this is Tom, and maybe you can discuss your enemies with him?
Tom:  Hi Patron, let's go sit down...
Librarian:  Next?

This is basically what popped into my head when I read OP's post.  This sounds like something that would be incredibly difficult to deal with and I'm glad there appears to be a solution on the horizon.

[camlan]

I just don't understand how it's going to be a solution at all, unless they're there to train library staff in how to handle the situation rather than dealing with the patrons directly. If the patrons need to be refused service and/or removed from the premises due to their behavior, then it seems like Security or the police are the appropriate people to handle it. Where do the mental health professionals come into the picture? They can't diagnose/treat someone for mental health issues in the middle of the library against their will!

The issue we had at my library was that frequently the patrons weren't doing anything that would get them removed from the library. It was more like the guy who would come up to the desk every 5 minutes to ask for a pencil and scrap paper, which weren't kept at the desk to begin with. He'd interrupt whatever you were doing with another patron and demand the paper and pencil. The security guard could tell him to stop. But that didn't *make* him stop.  But because he wasn't yelling or causing a disturbance, the security guards couldn't make him leave--there was a set of rules they had to follow.

So the guards could stand at the desk for a while, and he'd leave us alone while they were there. But they had other responsibilities in other parts of the building, and once they left the desk, Pencil Guy would be right back.

There were others like him--no behavior that was enough to get them removed, but behaviors that made it difficult to anything other than deal with them while you were out at the desk. I think if someone had to be removed from the library, the security guards had to call the police to do that.

I don't know what the plan is for the patrons at Yarnspinner's library. But since I assumed the "local mental health" people were a public health organization, and because they agreed to help, I figured that they had a plan and that the plan would be ethical and legal.

[LadyL]

Not having training in library running or assisting people with severe mental health issues, I imagine something like the following:

Library Patron, to Librarian:  Hi, I need a book on karate, also, I need you to watch the door for me because I am (name of heroine) and the bad guys are after me.  They are out to get me, because (goes into long explanation)...
Librarian:  I can help you find the book you are requesting. 
Patron:  But the guys are coming, I might have to fight them and...
Librarian:  Patron, this is Tom, and maybe you can discuss your enemies with him?
Tom:  Hi Patron, let's go sit down...
Librarian:  Next?

This is basically what popped into my head when I read OP's post.  This sounds like something that would be incredibly difficult to deal with and I'm glad there appears to be a solution on the horizon.

I worked on a neuropsych unit with people committed by the court system. Often the person interviewing the patient would sort of "buddy up" to the person - nod along in an understanding manner, say things like "wow that sounds stressful, to see martians breaking into your car", etc. Try to build a rapport. Nothing that involves protected health information or doing an exam, just being a welcoming figure and building trust. In the case of the library patrons, I could see the mental health team making treatment *referrals* - maybe even providing transport to something like a psych ER - but I highly doubt they're going to set up shop and do evals in the library in plain view. As others have said it would be highly problematic.

There are "street teams" that drive around and do outreach to homeless people, often trying to convince them to check in to a hospital or shelter. There are certainly ways to do outreach that are ethical, legal, and productive. I trust that yarnspinner would not be happy to report this development if there was a rouge gang of pirate clinicians kidnapping her patrons or something (as temping as it would be!)  .

[Tea Drinker]

As I understand it, one thing the street teams do is approach with "would you like a cup of coffee/some soup?" and try to lead into "we can give you a real bed, that would be more comfortable than sleeping on a subway bench" and then, maybe, mental health outreach if appropriate. (Not all homeless people are mentally ill, nor vice versa, and there can be rational reasons for someone, with or without a mental illness, to avoid homeless shelters: some such places are unsafe.)

Beyond that, the question may be partly what the library rules are, and when if ever a non-dangerous patron can be asked to leave for the day or longer. That's not just a mental health issue: mentally healthy people can be obnoxious, loud, or self-centered in ways that disrupt other people's work or study.

[Jocelyn]

Not having training in library running or assisting people with severe mental health issues, I imagine something like the following:

Library Patron, to Librarian:  Hi, I need a book on karate, also, I need you to watch the door for me because I am (name of heroine) and the bad guys are after me.  They are out to get me, because (goes into long explanation)...
Librarian:  I can help you find the book you are requesting. 
Patron:  But the guys are coming, I might have to fight them and...
Librarian:  Patron, this is Tom, and maybe you can discuss your enemies with him?
Tom:  Hi Patron, let's go sit down...
Librarian:  Next?

This is basically what popped into my head when I read OP's post.  This sounds like something that would be incredibly difficult to deal with and I'm glad there appears to be a solution on the horizon.

If Tom is there as a mental health professional, he would need to identify himself from the beginning, to avoid ethical violations.
Even when doing 'outreach', you have to identify yourself as a helping professional, even though you don't have to start with professional services (you can start by just talking, giving out food, etc).

Think about it this way: suppose those of you who are parents are out in public with your kids, and your child has a meltdown. How would you feel if someone came up to you and wanted to discuss your parenting with you? Would it make it better if she pretended at first to be just a friendly stranger, and only later identified herself as a child protective services worker? Wouldn't it be off-putting for you to have someone come up, and say, however quietly, that they were a social worker and you were obviously in need of her services? Would you want this to be legal?

[CaffeineKatie]

I don't know if the mental health professionals can approach the patrons, but they can surely observe patron/staff interactions and give the staff advice on handling the situations. I worked in a specialty reference department in a public library and we had a large number of reality-challenged patrons wandering through.  Some staff, with perhaps the best of intentions, would engage with the reality challenged patrons and either stir things up by insisting that they come back to Earth or make them permanent pests by adding fuel to their delusional behavior.  The rest of us answered basic library related enquiries, but learned to politely disengage, walk away, appear busy, etc. to defuse the situation (rantings, repeat behavior tics, and that sort of thing).  Some of us tried to share this, but to no avail--maybe the same advice coming from mental health professionals would have been accepted more readily.

And while the homeless and mentally have rights, other patrons have the right to feel safe using a library their tax dollars are paying for.  I'd say the OP's library has made a step in the right direction.  Good luck.

[esposita]

I could not agree more with Jocelyn. Where are we to draw the line?

Also, demanding help every five minutes from someone who has already assisted you could surely be defined as harassment, and the proper course of action for being harassed by a stranger (or someone you know) is to involve the police.

Oh, and by the way <waves hello> nice to meet you all! Long time lurker, first post ever!!

[poundcake]

But just because there is a fear about "slippery slope" and "where do we draw lines?" doesn't mean people should do nothing. Not only do I have several friends who are librarians, but I use my downtown regularly. At least, I used to. Living in a large city, the downtown branch attracted a large number of homeless and/or mentally challenged patrons due to the proximity of the city's skid row. Working in the stacks was down right terrifying at times. It wasn't just the crazy-eyed people talking to themselves, which was uncomfortable but part of everyday life. I experienced a number of very disturbing situations that made working there nearly impossible some days. I'm talking about people who smelled so bad of BO or urine/feces that not only could you not breathe, but the smell would linger for hours. Almost daily, some patron managed to look up porn on the public computers, and masturbated in clear view. There was at least one occasion that I know of when drug paraphernalia was found in the bathroom. If you needed to speak to a librarian or grab one more book from the shelf, you had to pack up all of your belongs and take them with you (and lose your table) because of theft. Disturbed patrons shook shelves and yelled, or threw books from shelves, which is very frightening, not to mention intimidating. Once, a man came and sat right next to me and just stared at me, mumbling things. Every single day, there was someone clearly mentally disturbed and/or on drugs wandering around the aisles talking to themselves and interrupting patrons and librarians. Even though security would try to quickly intervene, sometimes the disruption would continue. After a summer of daily issues like this, I just gave up using the library at all.

If the members of the community can no longer use the facilities, where do we draw lines there?

At least with the OP's library, not only are there going to be trained professionals available to assist, but they can also help assess the local needs, and help enact change in the local community so that the mentally ill are protected, but that average citizens are protected and able to use their community resources as well.   

[Yarnspinner]

Sorry, guys, I have been away and my computer at home doesn't work.

I guess I should have done more talking to my immediate supervisor before I came on and talked about what we are supposed to be doing.

Allow me to clarify!

The nice lady from the local city mental health department is coming here to:

a) talk with boss re safety/health concerns for staff as well as mentally ill patrons; some of this was precipitated (I just learned) by immediate supervisor's concern for two homeless, elderly men who were both asleep in the study room next door.  We aren't supposed to allow this to happen, however, one man was very sick from cancer treatments and pain meds and he could not wake up.  Boss has called EMTs who also had trouble waking him up.  Boss wanted to have a social worker or someone follow up with this man.  So he got in touch with mental health professional to discuss what can be done, if anything.

b) Mental health professional wants to watch us and see how the interactions go and then recommend ways we can gently get the more tenacious people, who see us as their best friends, to, well, go away for a while.

c) She also wants to assess our problems in general and see if there is a non-intrusive way to help some of these individuals.  Obviously we are not going to ask her to get on the case of Special Snowflakes or demanding patrons.    And we (finally!!!!!) have security (grudgingly hired by the library board after a couple of ugly stalking incidents) to deal with the people who get angry and start screaming/threatening. 

d) We really, really need help to deal with people like Titanic Guy who is mentally challenged,  and has kind of has a boy crush on our male staff members.  He will stand and talk to them by the hour and NOTHING makes him go away. We really don't want to call security because it isn't a safety issue--he just doesn't have any other friends and he thinks we are his best buddies.  He's also loud and sometimes verbally obnoxious....but he's also a very sad, defeated young man and no one wants to hurt him.  (What we sometimes do is quietly extend his time on the computer so he has less time to hang around the desk.)  Similarly, we need help with people who are hearing voices (Princess Talks to Herself has many, many invisible companions with whom she engages in lengthy debates and often leans in to hear what they have to say), who have major paranoia issues (Ms. I Am Not A lesbian Why Do They Talk To Me), and so on.

e) There was a precedent set some time ago, after one of our non-reality challenged but very nasty patrons took a dislike to a quiet, mentally ill man who likes nothing more than to do the NY Times Sunday crossword.  It is his word and the nasty patron started beating him up outside the library.  We got the police in for the nasty patron and tracked down the cross word puzzle man's social worker who got him into a new town and a new situation.  We managed to contact her recently and although she cannot tell us where he is, she thanked us profusely for helping her get him into a better situation where he is a lot happier and cared for. 

So, we aren't going to herd folks to the asylum.  It's more likely to be a learning experience for us and a training/field experience for the mental health professionals who will be observing our interactions.  And believe me, we will still call our security guys when The Book Thief starts stuffing books down his pants or Angry Man threatens to take a swing at me because I won't let him take out movies for free.

[Yarnspinner]

But just because there is a fear about "slippery slope" and "where do we draw lines?" doesn't mean people should do nothing. Not only do I have several friends who are librarians, but I use my downtown regularly. At least, I used to. Living in a large city, the downtown branch attracted a large number of homeless and/or mentally challenged patrons due to the proximity of the city's skid row. Working in the stacks was down right terrifying at times. It wasn't just the crazy-eyed people talking to themselves, which was uncomfortable but part of everyday life. I experienced a number of very disturbing situations that made working there nearly impossible some days. I'm talking about people who smelled so bad of BO or urine/feces that not only could you not breathe, but the smell would linger for hours. Almost daily, some patron managed to look up porn on the public computers, and masturbated in clear view. There was at least one occasion that I know of when drug paraphernalia was found in the bathroom. If you needed to speak to a librarian or grab one more book from the shelf, you had to pack up all of your belongs and take them with you (and lose your table) because of theft. Disturbed patrons shook shelves and yelled, or threw books from shelves, which is very frightening, not to mention intimidating. Once, a man came and sat right next to me and just stared at me, mumbling things. Every single day, there was someone clearly mentally disturbed and/or on drugs wandering around the aisles talking to themselves and interrupting patrons and librarians. Even though security would try to quickly intervene, sometimes the disruption would continue. After a summer of daily issues like this, I just gave up using the library at all.

If the members of the community can no longer use the facilities, where do we draw lines there?

At least with the OP's library, not only are there going to be trained professionals available to assist, but they can also help assess the local needs, and help enact change in the local community so that the mentally ill are protected, but that average citizens are protected and able to use their community resources as well.   

The bolded happens all the time.  My supervisor told one patron he could not return to the library until he showered and washed his clothes and the man told him to mind his own business and to leave him alone.  He left for weeks and boss felt dreadful because we are all actually fond of the guy but his stench was overpowering in a place that has only two functioning windows we can open and no air conditioning to speak of.  (That is a long story for another time.)  It's bloody hot in here and the reek was horrible.

And as for the second item, we have had to toss out whole groups of gents who gather round computers to watch pron and party with themselves.  But THAT is a security issue and one our guards take seriously.  (I felt for the young guard who told me about tossing a man who was looking at a book of nude sculpture and using it as, er, inspiration.  "It's my FIRST DAY," the guard kept saying.  "I DIDN'T KNOW PEOPLE DID STUFF LIKE THAT!"

We try to stay away from the slippery slope by using common sense and I know that the social workers will remind us when there is a situation we can fix and a situation we have to let go.  (It's possible I am going to have to say "Look, FDR Guy, I don't want to hear anymore from you.  Go away and let me work.")

[*inviteseller]

I understand calling them.  Where I used to work, in the downtown part of my area, we have a lot of interesting characters.  One in particular used to walk the sidewalks day in day out on our block.  He was harmless ..never bothered anyone, but he had issues.  We started noticing him being a bit more agitated and started getting worried about him so we called the county mental health hotline.  They sent someone to observe and they talked with him.  He ended up going to the psych hospital willingly with them and they were able to get him the help that he needed. 

Also, I completely sympathize with Yarnspinner.. our library system (well known, named for a famous industrialist) has a downtown branch that was just completely rebuilt and is gorgeous, except it is a hangout for all the crazies.  The homeless, the mentally ill, the left of center personalities.  My DD went to the branch to get some material for a school project that our tiny borough library didn't have, and she said she was scared the whole time because of all the strange people.  And when I have been in there, they do seem to be the neediest.  I watched one gentleman, who obviously was allergic to soap and water, pester the one librarian to keep coming out from behind the desk (where she was helping someone) to help him look for books on some scientist (can't remember the name but he kept yelling He is a scientist!!) .  It makes the people who want to go in with their kids, or the workers who want to browse during their lunch hour nervous.  The one librarian I got to know told me they refer to themselves as the XXXLibrary & Mental Ward. 

[aka]

Also, I completely sympathize with Yarnspinner.. our library system (well known, named for a famous industrialist) has a downtown branch that was just completely rebuilt and is gorgeous, except it is a hangout for all the crazies.  The homeless, the mentally ill, the left of center personalities.  My DD went to the branch to get some material for a school project that our tiny borough library didn't have, and she said she was scared the whole time because of all the strange people.  And when I have been in there, they do seem to be the neediest.  I watched one gentleman, who obviously was allergic to soap and water, pester the one librarian to keep coming out from behind the desk (where she was helping someone) to help him look for books on some scientist (can't remember the name but he kept yelling He is a scientist!!) .  It makes the people who want to go in with their kids, or the workers who want to browse during their lunch hour nervous.  The one librarian I got to know told me they refer to themselves as the XXXLibrary & Mental Ward.

Just fyi, it is not cool to describe people experiencing mental illness as "the crazies."