The trend in reduced funding for mental health services in the community and in hospital settings has continued into the twenty-first century as many states struggle to reduce huge budget deficits (Health Policy Tracking Service 2003). The consequences of this trend are fewer treatment options for people with mental illness and increased challenges for law enforcement agencies, because these agencies alone are responsible for emergency response for this population in crisis twenty-four hours each day, seven days each week (Finn and Sullivan 1987).
Law enforcement officers encounter people with mental illness in many realms— responding to calls for service from concerned family members, friends, and neighbors, conducting routine patrol of city streets large and small, and serving warrants and eviction notices. Because of the paucity of mental health resources, officers frequently must choose between leaving a person in crisis with only a short-term resolution and taking that person to jail.
When the person with mental illness is a crime victim, law enforcement faces complex evidence collection scenarios, because these individuals may confuse their victimization history as a consequence of their illness and be considered unreliable witnesses (Council of State Governments 2002). When confronted with the fact that people with mental illness are victimized disproportionately (Teplin 1999; Hiday et al. 1999), this situation becomes particularly challenging for law enforcement investigators and those organizations that provide resources to crime victims.
Many law enforcement personnel consider situations involving a person with mental illness to entail significant challenges (Borum et al. 1998; Deane et al. 1998). These encounters can be time consuming (DeCuir and Lamb 1996; Pogrebin 1987), can escalate quickly, and may result in injuries—or, more rarely, even in deaths—to officers and citizens.
Several law enforcement agencies have tracked the number of calls related to people with mental illness. For example, in New York City, the police department responds to a call involving a person with mental illness once every 6.5 minutes (Fyfe 2002). And, in one year, law enforcement officers in Florida transported a person with mental illness for involuntary examination (Baker Acts) more than forty thousand times, which exceeds the number of arrests in the state for aggravated assault or burglary. And, in 1996, the Los Angeles Police Department reported spending approximately twenty-eight thousand hours a month on calls involving this population (DeCuir and Lamb 1996).
The number of people with mental illness in jails and prisons reflects how often encounters with people with mental illness result in arrest—often for minor, disturbance-related offenses. For example, the prevalence rate of current severe mental disorder is estimated at 6.4% for male detainees entering the Cook County, Illinois, jail (Teplin 1990) and 12.2% for female detainees (National GAINS Center for People with Co-Occurring Disorders in the Justice System 2001).
These circumstances have propelled concerned community members and law enforcement officials to change their response policies and practices—both to improve outcomes for people with mental illness and to reduce injuries to all involved. Deane and her colleagues (Deane et al. 1999) surveyed the law enforcement agencies serving populations greater than a hundred thousand in the United States and identified three distinct models, two of which involve substantial changes in law enforcement policies and practices. This article reviews these important enhancements and program goals and achievements and discusses critical issues agencies face when attempting to implement such programs.
Specialized Police Responses to People with Mental Illness
Attention has increasingly focused on the work of law enforcement agencies in improving responses to people with mental illness (Reuland 2004; Council of State Governments 2002), and two centers receive federal funds to provide technical assistance to these communities (http:// www.Consensusproject.org; http://www.gainsctr.com). The Criminal Justice/ Mental Health Consensus Report offers a comprehensive series of policy recommendations for law enforcement, courts, corrections, and mental health. A multi-disciplinary advisory board composed of experts in mental health, advocacy, and law enforcement developed the recommendations based on the pioneering work of several law enforcement agencies (including Memphis, Tennessee, and San Diego County, California) and their own expertise.
These agencies developed two police-based approach styles: the crisis intervention team (CIT) response, where a cadre of specially trained officers responds to calls involving people with mental illness (Memphis Police Department), and a co-response model, where certain law enforcement officers pair with mental health professionals to offer crisis intervention and referral services while at the scene. A critical component to these programs is that officers volunteer to be a part of the program and must go though a selection process before they are chosen.
The Consensus Project Report provides guidance for developing such programs, but the report does not specify a particular model or approach. Instead, policy recommendations are offered for more than twenty decision-making points—from an initial failure to receive adequate mental health treatment to a release from incar-ceration—where criminal justice and mental health professionals must choose how best to respond to this population. It is left up to individual jurisdictions to decide where to focus their efforts (most likely where they are experiencing a problem) and which model to implement.
Several additional publications document in greater detail how law enforcement agencies in the United States have built on the work of the earlier innovators to develop these specialized police responses to people with mental illness. The Police Executive Research Forum (PERF) interviewed almost thirty agencies on two occasions to learn how core program elements—such as specialized training and partnership with mental health professionals—affect the police response from the initial point of contact through disposition (Reuland 2004; Reuland and Cheney 2005).
Goals and Achievements
Research done to date on these specialized approaches (Deane 1999; Steadman 2000; Council of State Governments 2002; Reuland 2004) has identified several core program elements, including mental health collaboration and specialized training. Program goals typically reflect a desire to improve these elements. For example, many communities aim to develop training for officers to improve their understanding of mental illness and crisis response in this population, while others hope to better their relationships with mental health professionals, people with mental illnesses, and their families. Agencies also seek to reduce injuries and provide better services to people with mental illnesses (Reuland and Cheney 2005).
Although long-term program outcomes have not been fully evaluated (Steadman 2000), agencies report that programs have achieved a great deal in the short term; many report that officers now have greater information and understanding about mental illness and have built strong, effective relationships with the community. Other data demonstrate that specialized responses reduce the frequency of arrest of people with mental illness (Steadman 2000). In addition, some jurisdictions report fewer injuries and SWAT team call-outs (Reuland and Cheney 2005). A vast majority of the agencies PERF surveyed noted that strong partnerships with mental health service providers and people with mental illness and improved awareness of mental illness are critical to fostering better long-term outcomes for people with mental illness.
Core Element: Training
Agency training is so critical because so many different law enforcement staff members—from dispatchers, who must assess the nature of the call and dispatch it appropriately, to patrol officers, who must de-escalate crises and select appropriate responses—play a crucial part in successfully handling calls involving people with mental illness. Like this nation’s population, however, some of these personnel lack information and skills critical to responding effectively to these encounters.
Existing academy training requirements on effective response to people with mental illnesses are typically limited—most states require only two- to four-hour training blocks for officer certification, with little or no follow-up training required. The specialized approaches provide extensive training blocks—often forty hours— about mental illness assessment, crisis de-escalation techniques, and ways to determine appropriate responses to calls for service involving mental illness.
Several challenges exist for agencies implementing specialized training. For example, there is a lack of qualified trainers locally, and smaller or rural areas may lack resources either to send officers to outside training or to pay outside experts. In addition, although some topics related to policing and people with mental illness are standard, many topics must be tailored to a locality’s available resources and philosophy about their response. This takes time and expertise and can be costly for communities with limited resources.
The Consensus Project report recommends that law enforcement agencies develop curricula in collaboration with mental health professionals, advocates, and consumer groups to offset these challenges (Council of State Governments 2002). The training should consist of standardized sections that provide an issue overview and teach skills needed to identify behavior that may be caused by a mental illness, to deescalate a crisis situation, to select the most appropriate police response, and, if needed, to reduce use of force. Additional sections should reflect local circumstances, and the training must offer opportunities for experiential learning. These training techniques are not didactic and can include ride-alongs, both with police and crisis workers, and visits to local mental health centers. These training events share day-to-day experiences of people with mental illness with officers who serve them and enlighten mental health partners about the realities of law enforcement.
Core Element: Collaboration
Strong collaboration among local advocates, consumers, medical and mental health professionals, and law enforcement will directly impact the quality and continuity of services provided to people with mental illness. Such collaborations promote effective communication on policy development, including ways to effect timely transfer of people with mental illness to the mental health system and to access mental health specialists on scene. Working in partnership with various stakeholders also supports innovative solutions to intransigent problems.
Collaboration is particularly important for programs aimed at diverting people with mental illness from jail. Diversion requires patrol officers to make a decision that a person would be more appropriately served through mental health treatment. And, although police officers may know about the availability of mental health services, department policy or state legislation may create pressure to select the “safest” response to avoid liability. Officers may fear that responses other than arrest may result in injury to the person or others or that the person will not receive proper treatment and will be back “on the streets.” Therefore, an officer’s fear of civil and criminal liability may prohibit him or her from selecting an alternative, perhaps more appropriate, response to people with mental illnesses. Collaboration with mental health partners can shape policies to encourage well-trained officers to use their discretion to select the most appropriate response, not the “safest” response.
In the PERF interviews, the agencies agreed that the police executive is crucial to the collaboration, as are mental health professionals, advocates, and consumers. However, some stakeholders may be more motivated than others and may face challenges engaging needed partners. The key to overcoming this challenge in all types of partnerships is to make sure that partners have a stake in the problem. Law enforcement agency executives are not likely to partner with mental health providers if they do not see that there is a problem with the current response. Similarly, mental health providers may be reluctant to partner with police if they perceive that the enhanced response will overtax already strained community resources. Partnership success is often a function of strong interpersonal relationships at the executive level, but this foundation can falter from staff turnover. An antidote to this challenge is the involvement of all organizational levels in transformational learning experiences noted above and in crafting the program within the agency from the outset.
Critical Considerations for Law Enforcement
Program implementation of any kind in law enforcement agencies is challenging. For specialized approaches such as those described here, demanding close partnerships with several disciplines and focusing on mental illness (around which significant stigma exists), several considerations are paramount for success.
First, as law enforcement approaches to improving the response to people with mental illness proliferate and become adapted, agencies will have more choices about which program elements and features to implement. It is critical that communities spend time adapting the approach to make it fit within the jurisdictional confines. The factors that may affect which program is best for the jurisdiction include, among other things, the department philosophy and community mental health resources. For example, CIT programs are well suited to agencies that support specialized teams. For agencies that follow a more generalized approach to policing, variations on the CIT model will likely be more appropriate and encounter less resistance.
Second, these specialized approaches require police officers to fill a crisis management role that is quite distinct from crisis management in other situations. For example, officers are typically trained to display their authority to gain control of a situation. In situations involving people with mental illness, however, officers must downplay this authority—by standing back and speaking softly in a nonthreaten-ing way—since authoritative displays can exacerbate the crisis situation. Officers who choose to become involved in the specialized response—and volunteering for this role is strongly suggested by agen-cies—they must be able and ready to switch their tactics, depending on the assessment they make of the situation. The recruitment and selection process for these officers therefore is critical.
Third, because evaluation is so important to securing state and federal funding, practitioners must build into their programs mechanisms for measuring their success. Evaluation requires that communities set measurable goals and objectives and be able to track their progress with objective data collection. When an agency or community decides that it is going to embark on such a program, evaluation must be considered at the outset of program development so that baseline data may be collected against which future processes and outcomes can be compared.
Law enforcement agencies typically face challenges in collecting data about patrol situations that do not involve a crime. Although patrol officers may complete forms for incidents, they predominantly collect information for those calls that result in arrest, and the information is tailored to other reporting requirements. As a way to collect information on specialized police responses to people with mental illness, many agencies have required officers to complete a tracking form designed specifically for their response protocol. These forms typically capture information related to the cause of the disturbance, the behavior of the person with mental illness (including violence and alcohol or drug use), and the disposition. Data collection also permits partners to communicate about problems that arise and develop solutions to manage them.
Future Directions
In recognition of the promise of these kinds of specialized approaches, the Mentally Ill Offender Treatment and Crime Reduction Act (Sec. 1194), was approved by Congress and signed into law by the president in October 2004. If appropriated at the recommended level, this law would authorize $50 million in federal grants to promote criminal justice and mental health agency collaboration at the state and local level to improve responses to people with mental illness who come to the attention of the criminal justice system. Grants can be used to develop pre-and postbooking interventions (including crisis intervention teams and law enforcement training), as well as other diversion programs in court and correctional settings (http://www.consensusproject.org).
This law will allow more communities to attempt these types of specialized approaches. As these communities innovate and explore these programs, continual adaptation will occur. This situation presents a unique opportunity to conduct more rigorous evaluation of these approaches to determine which elements have the most impact on the stated goals—perhaps most important, the goal of improving the health and well-being of people with mental illness.
