Police Response to People With Mental Illness

During the last third of the 20th century, dramatic changes in regard to the treatment of people with mental illnesses occurred. In particular, the development of antipsychotic medications meant that many people, particularly with psychotic illnesses such as schizophrenia and bipolar disorder, who had formerly been untreatable, were now able to receive medical treatment that effectively reduced many of their symptoms. At the same time, changes in mental health legislation resulted in an increase in the rights and privileges accorded to people with such problems. In combination, these factors resulted in significant numbers of people with mental illnesses being discharged from psychiatric hospitals and, thus, living in the community. This contributed to a substantial increase in the number of interactions between police and people with mental illnesses. Since that time, police organizations have been developing a number of initiatives and programs to address this situation.

Nature and Causes of Police Interactions With People With Mental Illnesses

While on the surface these major shifts were advantageous to people living with mental illnesses, there were a number of unforeseen consequences from this mass deinstitutionalization. In most countries, governments did not anticipate or provide sufficient support for people with mental illnesses living in the community. Inevitably, this led to an increase in the involvement of people with mental illnesses with the criminal justice system in general and, in particular, a dramatic increase in the number of interactions between people with mental illnesses and police.

Although reliable data are difficult to come by, it has been estimated that 7–15% of police calls might involve a person with a mental illness or a mental health problem. The question of whether people with mental illnesses are actually more likely than other people to participate in criminal activity is complex. There is evidence that mental illness in combination with substance abuse can lead to an increase in criminal activity. However, it does not appear that an increase in criminal activity by people with mental illnesses is the primary reason for the increased number of interactions between police and people with mental illnesses. In fact, most interactions between police and people with mental illnesses do not involve criminal activity. There are a variety of reasons why PMI might come in contact with the police:

• most mental health legislation includes a provision for police to apprehend people who appear to be experiencing a mental illness under certain conditions and take them to a psychiatric facility for assessment; this usually occurs in situations in which the person is perceived to be a danger to him- or herself or to someone else;
• people with mental illnesses, particularly when they are unwell, are at higher risk to become victims of crime and, therefore, might come in contact with the police when they have been victimized as opposed to being perpetrators of crime;
• people with mental illnesses are at much higher risk of becoming homeless;
• the families of persons with mental illnesses often resort to calling the police when their relative appears unwell and in need of treatment, but the person with mental illness might not be agreeable to going voluntarily to the hospital to receive such treatment; hence, police might use the authority of mental health legislation to take such persons involuntarily;
• police might, and indeed often do, play an informal social support role with people with mental illnesses, informally keeping track of them and looking out for their well-being; and
• some people with mental illnesses do in fact participate in criminal behavior and come to the attention of police in this context.

Because of the often inadequate mental health services, many people with mental illnesses have their first contact with the mental health system through the criminal justice system. Police can even be viewed as the gateway to the mental health system for persons with mental illness or mental health problems.

Even though attending to vulnerable populations, such as those with mental health problems, is an integral part of police work and consistent with the fundamental principles of contemporary policing, the involvement of the police might also contribute to undue stigmatization of mental illnesses. In addition, police have traditionally not been well equipped with the skills and knowledge necessary to interact constructively with people who might be acutely ill. This can be due to several reasons. One is that sometimes police officers are hired who are not suitable for some aspects of police work. Another is that sometimes basic training of new police officers as well as ongoing in-service education and training is insufficient to prepare police personnel for working with vulnerable persons. As a result, some interactions have not gone well.

When one looks at statistics related to use of force by police and their interactions with the public that result in a death, people with mental illnesses are clearly overrepresented. Consequently, starting in the mid-1990s, there has been increased emphasis within police agencies and police academies to develop skills and knowledge on the part of police officers to understand and interact with people with mental illnesses and to form greater and more constructive linkages with the mental health system.

There have been two areas of particular focus in regard to improving outcomes of police interactions with people with mental illness. The first of these has related to providing not only additional education and training for police personnel but also a wider variety of education and training that will enable positive outcomes. The second relates to the development of specialized teams and services within police agencies to respond to calls for service that might involve a person with a mental illness.

Education and Training for Police Personnel

By the early 21st century, it had become fairly standard for police academies to include at least a minimal number of hours of training and education about mental illness for police officer candidates. Typically, such curricula include the following:

• understanding the basic signs and symptoms of mental illness,
• the common types of mental health diagnoses and treatments,
• assessing and responding to suicidal people,
• verbal interaction and de-escalation skills,
• the powers and limits accorded to police under mental health legislation, and
• the options available to police when they encounter a person who appears to have a mental illness.

While some research has been conducted in regard to police interactions with people with mental illnesses and the learning necessary to maximize positive outcomes, overall, substantial additional research is required. In particular, research that is focused on how effective current learning programs are and how learning will be retained by police officers over time and applied under sometimes stressful circumstances is necessary. The extant research in regard to the efficacy of such education and training is inconclusive, as it can be difficult to determine exactly what components are most effective in changing police behavior. Moreover, it is also difficult to measure actual changes in behavior. In addition, curricula are highly variable from one police academy or organization to another. Many studies report an improvement in knowledge and attitudes on the part of police following training. Nevertheless, it has become generally recognized that education and training in this area should be multifaceted and ongoing, and needs to focus on a variety of factors including stigmatizing attitudes, factual knowledge, skill acquisition, and active problem-solving.

One comprehensive contemporary framework that has been developed by the Mental Health Commission of Canada and supported by the Canadian Association of Chiefs of Police is TEMPO, an acronym for “Training and Education about Mental Illness for Police Organizations.” It reflects a multilevel and continuing education focus for all personnel of a police organization, including not only police officers but also personnel such as call takers, dispatch personnel, and victim service workers.

TEMPO, in part, draws on the foundations from Crisis Intervention Teams (CITs, described in the next section) as well as the international literature and a review of the various curricula used in police academies in many different countries and jurisdictions. In addition to knowledge and skills, it focuses on active problem-solving, addressing stigma, ethical conduct, human rights, and utilizing a systems approach to interactions with people with mental illnesses. Overall, it emphasizes that design and delivery of police learning must be in conjunction with persons with mental health problems.

Police Response Models

While education is an essential component for the preparation of police for successful interactions with people with mental illness, there is also a need for specific program and service delivery developments—appropriate response modes. Probably the most well-known and well-researched police-based response model is the CIT, often referred to as the Memphis model since it originated in Memphis, TN. This is arguably the predominant model in the United States. Its focus is on developing a critical mass of highly skilled and specially trained police officers within a police agency who serve as resources to other police first responders.

When a patrol officer encounters a situation involving a person with a mental illness, the officer is able to contact a member of the CIT who can assist in the resolution of the situation. These specialized officers have received extensive training about mental illness and are also involved in developing liaisons with the mental health services in their jurisdiction. A key component of the CIT model is the formation of alliances between specific mental health services and the police organization, so that police have options and resources that might assist them in dealing with situations involving persons with mental illnesses when neither hospitalization nor criminal charges are appropriate.

However, the CIT police-based response model is not the only response model designed to work with people with mental illnesses. In some jurisdictions, co-response models are more common. There are varying forms of co-response models, but the essential feature of these models is that a police officer and a mental health worker (who might be a nurse, a social worker, a psychologist, or other mental health worker) respond jointly to calls involving a person who appears to have a mental illness. In Canada, co-response models are the predominant model. It has been hypothesized that one reason for this is that the lower overall rate of violence in Canada leads to a perception that it is safer for mental health personnel to be directly involved at the time of first response.

Co-response models might take a variety of forms. In some instances, the teams are first responders and respond directly to calls that appear to involve a person with mental illness, whereas in other cases, they might provide a secondary response after the initial response by a patrol officer. Co-response models might be based in either a police organization or a mental health organization with personnel from one organization being seconded to the other. This type of model also helps to deal with the barrier that often prohibits information sharing between police and mental health agencies and, therefore, might result in more effective disposition of individual situations.

Because of the variability of the different coresponse models, it is difficult to assess their efficacy and to compare them with CIT-type responses. There is evidence that both of these response models tend to reduce the number of apprehensions of people with mental illnesses by police pursuant to mental health legislation as well as arrests for apparent criminal behavior. There is some evidence that officers who have received CIT training might resort to less use of force in their interactions. There is also some evidence that there is an increased number of linkages between people with mental illnesses and mental health agencies when CIT officers are involved. Similarly, a review of co-response approaches indicates a variety of positive outcomes, including an increased number of linkages with the mental health system, a decrease in the number of hospital admissions, and a decrease in the amount of time that police spend in their interactions with people with mental illness. Some studies have also indicated that such models are cost-effective overall.

A few larger police agencies have also developed case management processes for people with mental illnesses, whereby particular individuals who tend to be heavy users of police resources are the focus of individualized case management plans developed jointly by the police organization and its partner mental health agency as well as appropriate social agencies. This type of service is often useful and effective in community management of individuals with severe personality disorders.

Police-based programs to address the needs of people with mental illnesses often—and ideally— work in conjunction with other community programs such as mental health system–based crisis line and crisis services, mental health courts, other diversion programs, social services, and hospital-based services including emergency rooms and psychiatric facilities.

The Strategic Approach

While all of the aforementioned approaches appear to be promising and there are data that support their effectiveness to some extent, it has become increasingly apparent that the mere presence of an add-on program or specialized team within the police agency is not sufficient to address the many and complex problems identified earlier that might involve vulnerable people including those with mental illnesses. In addition, while such programs might be cost-effective and practical in larger jurisdictions, smaller towns and cities as well as more rural jurisdictions are not likely to be able to support such specialized programs given the relatively smaller number of calls that might involve people with mental illnesses. Therefore, since about 2012, there has been an increasing tendency for police agencies to consider the development of a comprehensive strategic approach to address the complex needs of vulnerable people, in general, and people with mental illnesses in particular.

A strategy, as opposed to a discrete program, includes an emphasis on the root causes of problems as opposed to focusing predominantly on the symptoms of a problem. In the case of police interactions with people with mental illness, a strategy is likely to reflect the need for an organizational culture that reduces or eliminates stigma related to mental illness and focuses on human rights, procedural justice, and reduction of criminalization. Typically, such a strategy would focus on increasing the likelihood that interactions between police and people with mental illnesses result in positive outcomes; that police are part of a comprehensive community system involving government and nongovernmental organizations including not only health and mental health organizations but also those that support housing, income education, and employment; that approaches to interactions with persons with mental illness reflect not only the mental health needs of the individual but are also needs specific to gender, culture, language, and local community needs; and, arguably most important, that police interventions are both proactive and reactive.

Of note is that a strategy includes and directs the need for the development of appropriate educational initiatives and specific programs, but goes beyond that and recognizes that police might interact with people with mental illnesses in a wide range of circumstances, and that, therefore, no single stand-alone program will address all possible circumstances. As of 2015, very few police organizations were taking a strategic approach; however, it appears that the Los Angeles Police Department is one police agency that takes such an approach. The Ontario Provincial Police, Canada, have recently developed a comprehensive strategy to address not only their interactions with people with mental illnesses but also the mental wellness and understanding of mental health in the police workplace. These are both bold initiatives that could be emulated in the interest of improving outcomes for persons who have mental health problems within as well as external to a police organization.

References:

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2. Coleman, T., & Cotton, D. (2014). TEMPO: A contemporary model for police education and training about mental illness. International Journal of Law and Psychiatry, 37(4), 325–333.
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4. Compton, M. T., Bakeman, R., Broussard, B., Hankerson-Dyson, D., Husbands, L., Krishan, S., & Watson, A. C. (2014b). The police-based crisis intervention team (CIT) model: II. Effects on level of force and resolution, referral, and arrest. Psychiatric Services, 65(4), 523–529. doi:10.1176/appi.ps.201300108
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