Jail Diversion: Reduced costs by spending more on mental health

PART 1

WESTBOROUGH, MA July 6, 2017 Jail diversion is a hot topic across the country. The numbers of persons incarcerated for minor offenses and drug crimes has grown. Many of these individuals have mental illness or drug abuse in addition to their criminality. The interaction between poly-substance abuse or dependence and exacerbation of underlying mental health symptoms is complex. It is the focus of mental health advocates and criminal justice experts nationwide as it pertains to jail diversion and reduced use of force among law enforcement.  In Massachusetts, there is a move away from mandatory minimum sentences for all drug crimes except for those involving the distribution of narcotics. Arguably, the impact on behavioral functioning when persons are gripped with co-occurring illness is a recurrent problem for law enforcement and first responders. I have written about the impact of co-occurring illness such as alcoholism on mental and behavioral health is previously published posts here on Word press Human Behavior (Sefton, 2017). It is difficult to uncover which comes first – the addiction or the diagnosed mental illness and yet they are inextricably linked in terms of the strain on public resources and health risk to those so afflicted. Why is this important?

The importance of treatment for substance dependence and mental illness cannot be understated as violent encounters between law enforcement and the mentally ill have been regularly sensationalized. The general public is looking for greater public safety while at the same time MH advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. The referral infrastructure to provide a continuum of care in this growing population is available in very few places across America.

Models of Care

Yet in places like Bexar County, Texas the county jail population has dropped by over 20 percent as a result of crisis intervention training for police officers and mobile mental health teams to intervene with those in crisis. I have seen this for myself during a visit with the San Antonio Police Department where I rode with two members of the Mental Health Unit – Officers Ernest Stevens and Joseph Smarro. It takes training, medical and psychiatric infrastructure, community compassion, and active engagement with members of the community often left to fly under the radar to effectively reduce the jail population. When necessary those most in need must have 24-hour availability for detoxification, emergency mental health, and access to basic needs such as food, clothing, and medicine. In San Antonio they offer so much more including pre-employment training, extended housing, interview preparation including clothes, and opportunity for jobs.

Behavioral Analysis and Law Enforcement

The unpredictability of behavior in those who carry a “dual” diagnosis has emerged in the criminal justice system when jail diversion programs and treatment options are brought forth raising the specter of frustration over the limitations within the system. Cities everywhere are grappling with how best to intervene with the mentally ill in terms of alternative restitution for drug-related misdemeanor crimes in lieu of mandatory jail sentences that many crimes currently require. Some believe, as much as 20-40 percent of all incarcerated persons suffer with mental health diagnoses and are not getting the treatment they require. To provide a bare bones system would add billions to state and federal dollars spent on the needs of inmates at a time when measurable outcomes for in house care are limited.

In my practice I see many cases of co-occurring pain syndromes with other physical debility such as stroke or traumatic brain injury. Generally the emotional impact of two or more diagnosed illnesses yields a greatly reduced capacity for adaptive coping and puts a great stress on the individual system. The importance of addressing co-occurring substance abuse or dependence is now well recognized and with treatment can result in healthy decision-making, growth in maturity, and greater self-awareness. If legislators have a serious desire to reduce statewide numbers of incarcerated persons a comprehensive plan must be considered for both pre-arrest and post-arrest. Infrastructure for enhanced understanding of addiction and greater treatment options must be explored through a joint public and private initiative.

PROPOSED JAIL DIVERSION INITIATIVE

PRE-ARREST JAIL DIVERSION – No crime committed

If police encounter subjects with a known history of mental illness through their community policing efforts they should return the subject to his family or primary psychiatric caregiver – this might be a physician, physician’s assistant (PA), a nurse practitioner (NP), even a psychologist for immediate crisis intervention. Depending upon the nature of the police encounter such as during the nighttime hours the subject may be transported to a local emergency department for psychiatric evaluation. This model has grown less popular because of the growing wait times in local hospital emergency departments – especially for those suspected of mental illness and tends to make them increasingly agitated. Persons with mental illness are often homeless and come into police contact simply on the basis of panhandling or looking suspicious and out of place in the neighborhood. Often they are reported to police because they are talking to themselves, suspicious, and menacing toward pedestrians making them afraid.

The hospital alternative might be to establish regional psychiatric emergency intake centers available 24-hours daily. At one point states had regional hospitals that have been closed down releasing thousands of institutionalized patients into the community. The plan for de-institutionalization was to provide a neighborhood center at which the patient could continue his or her treatment and receive their needed medication to keep them symptom free.

Minor crime committed

When a crime is committed by someone with known or suspected mental illness such as simple assault, disorderly conduct, or shoplifting the responding police officer’s will have discretion whether to bring forth charges or not in exchange for an alternative disposition that would defer jail time. These are not new concepts. Law enforcement has always had the discretion to arrest or not arrest for many minor offenses. The choice often comes down to the subject demeanor and his response to police officer directives at the time of the encounter. In some cases an officer must arrest such as in the setting of domestic violence, child abuse, or as a result of a felony being committed.

In these cases charges may be brought and held as long as the subject entered treatment or remained abstinent from use of drugs or alcohol – the jail diversion plan. If they failed to follow the terms of their diversion plan the charges would be re-instated and sent to district attorney for prosecution.  The alternative is a revolving door of addiction and petty crime that, at times, will escalate into violent crime. As a society more can be done to reduce criminality and jail diversion through empathic, sensitive treatment options.

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Forensic Mental Health: Contemporary Issues and Interactions Involving Justice-Involved Persons with Mental Illness

neacjs-logo-US-left-colorv21-300x251WESTBOROUGH, MA April 30, 2017 The Northeastern Association of Criminal Justice Sciences has announced the date for its upcoming annual conference to be held in Rhode Island at Roger Williams University in Bristol.  The conference will be held on June 7-10 2017.

The topic this year is Forensic Mental Health: Contemporary Issues and Interactions Involving Justice-Involved Persons with Mental Illness that has been in the news when it comes to police encounters with those so afflicted.  In Massachusetts alone over 120 people thought to suffer with mental illness have been involved in lethal force situations with law enforcement between 2008-2016.  The program is still being drafted but I have been invited to present the Psychological Autopsy as a Forensic Tool along with my colleague Brian Gagan and co-author of the Psychological Autopsy of Steven Lake – Dexter,

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Dr. Sefton discussing psychological autopsy of Steven Lake with coauthor Brian Gagan (left)

Maine Homicide-Suicide in 2011.

Police are building bridges and throwing life savers

WESTBOROUGH, MA  – March 30, 2017  Police officers are being trained in crisis intervention techniques across the country and Canada. This training offers plenty of practice role-playing scenarios that come directly off of the call sheets affording a reality-based training opportunity. I recently spent time riding with members of the San Antonio PD mental health unit and have the greatest respect for the officers with whom I rode.  In contrast, some departments regularly have highly trained clinicians riding with officers bringing expertise in mental illness and abnormal behavior across the thin blue line.  It is thought that by sharing knowledge at working with unpredictable, drugged out, psychotic and delusional and angry who police encounter on a daily basis better outcomes may be achieved. No single model is best and all are still in the growing stages of establishing protocols for bringing those most disturbed individuals in from the margins. More and more officers are receiving CIT training every year.

The important part of crisis intervention training comes in the interdisciplinary relationships that are forged in by this methodology. Trust and respect between the police and its citizens builds slowly one person at a time.  Community policing is not a new concept but fiscal priorities often prevent its full implementation.  Just the same, there must be trust and respect between the police and the purveyors of crisis intervention and mental health risk assessment including doctors, nurses, and health care practitioners. This also takes time and training and the shared belief in the model.


“When officers are faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures,” according to Grace Gatpandan, spokesperson for the San Francisco Police Department


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Michael Sefton, Ph.D. in 2017 photograph

The use of force continuum belies each officer contact and guides the process when police are called upon to defuse a dangerous encounter. It is best that a mental health contact be made long before violent threats are made – long before terminal rage erodes personal judgment. The community policing doctrine affords this front end contact and encourages officers to know the people living on the beat.

POLICE ENCOUNTERS WITH MENTALLY ILL CITIZENS

The Boston Globe Spotlight series on police encounters with the mentally ill cites one distraught parent who was quoted “I only wanted the police to disarm him not shoot him dead.” Unfortunately for this family, when faced with lethal violence it is the behavior of the subject that drives the ship in terms of what will or will not happen.  “When faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures”. All too often people fail to see the cause – effect relationship between citizens with guns or other lethal weapons and the police officer response.  The use of force continuum follows the principle of causation by guiding police decision making based on the level of threat.

What came first the threat or the police action?  It is the primary action of the citizen the evokes the lethal response by police.  If citizens dropped weapons and listened to police officer directives during these high energy and chaotic events there would be fewer deaths.  To say they lack training in mental health is preposterous.  Almost as preposterous as saying if they were better parents the mentally ill subject might not aim his gun at police or threaten his mother with a knife.  No, the responsibility lies with the mental decision-making and subsequent behavior of the subject himself.  If mental illness drives the violent behavior than all weapons and substance use must be carefully controlled and eliminated.  When people attend psychotherapy sessions and 12-step recovery programs the proclivity for violence is greatly reduced.  Inevitably, drug abuse is a co-morbid factor that alters perception and fuels underlying anger and violent tendencies.  Who is responsible for this? When drug addition or alcoholism begin – all emotional growth including adult “problem solving” begins to fail until it is fraught with uncontrolled, impulsive violence. Rather than placing blame, greater emphasis on sobriety, counseling and developing emotional resiliency should be encouraged.


Lowery, W. (2015) DISTRAUGHT PEOPLE, DEADLY RESULTS: Officers often lack the training to approach the mentally unstable, experts say. http://www.washingtonpost.com/sf/investigative/2015/06/30/distraught-people-deadly-results/?utm_term=.86e44d33dfab Taken March 5, 2017

What are “collateral consequences” in domestic violence?

WESTBOROUGH, MA March 21, 2017 When working as a police officer I was asked to take the statements of women who were asking for protection from an abusive spouse or intimate partner.  These requests were usually granted by the on-call judge – especially if children were at risk or a history of physical abuse was suspected.  But these orders only last a short time – perhaps a weekend.  In order to have restraining orders extended the victim is expected to go to the district court and swear testimony that specifies the reasons for an order of protection including threats or actual physical harm, forced sexual contact, pathological jealousy – whatever.  Sometimes this happens and protection orders are extended usually for 6 months. During this time the couple is expected to sort out their differences and engage the help of a family therapist, if possible.  This rarely happens.


“Domestic violence is not random and unpredictable. There are red flags that trigger an emotional undulation that bears energy like the movement of tectonic plates beneath the sea.” according to Michael Sefton.  A psychological autopsy should be undertaken to effectively understand the homicide and in doing so contribute to the literature on domestic violence and DVH according to Sefton who with colleagues published the Psychological Autopsy of a case from Dexter, Maine where a father murdered his children, estranged wife and ultimately himself (Allanach, et al, 2011).


More often than not, the victim fails to appear for this process and the protective order goes away without any consequences. Why? In the time between the initial emergency order and the Monday morning when the victim is expected to substantiate her initial claims she may have been bullied by her spouse and worked over by his family, his friends and whomever he can enlist in his camp to get her to let it go. She is made to believe that she cannot function without her abuser.  When children are involved an abusive spouse will usually say that child protective services will take the children for whatever reason he comes up with.  He promises to destroy her credit worthiness, she will be penniless, and he threatens to share lies about her on social media pages for all to see. He may also promise to kill her and cut her to pieces to be used as fish bait – as I have been told in a case being investigated by my former agency. But he swears his love for her always.

This happens over and over.

In some cases the order to extend the restraining order results from elevated risk to the victim and recurring threats of violence. In these cases orders of protection go on for months or years at a time.  This type of bullying is an example of the often secretive coercion that takes place in DV and intimate partner abuse is flagrant and often goes unreported.  It must be considered whenever an initial order is not sustained especially if the victim fails to appear.

In some cases there is more than one order of protection issued to protect one or more intimate partners. This is a red flag and should have bearing on the bail requirements but seldom does. There should be some follow-up with the original complainant by the police department to investigate her reasons for not pursuing the extended order of protection and determine what impact bullying may have played on the victim’s decision.  In rare cases permanent orders are granted because of compelling evidence that the victim and her family remains at risk – usually the result of stalking.

In March 2014, I published a blog in which the Massachusetts Supreme Judicial Court granted a permanent restraining order even though the former spouse was living in Utah and was remarried. In 2014 the Boston Globe did a story on the case written by Martin Valencia essentially raising the spector of the abuser in this case and the current impact the court order has on his day to day life in Utah.

Kevin Caruso was unable to get a job as a youth baseball coach because of a continuing order of protection here in Massachusetts that shows up on his CORI report. He could not own a firearm and was sometimes hassled at airports. The SJC ruled that Kevin Caruso must submit “clear and convincing evidence” that he no longer poses a danger to former girlfriend in a case dating back to 2001.  The Supreme Judicial Court  in Massachusetts has required that Mr. Caruso provide proof that “he has ‘moved on’ from his history of domestic abuse and retaliation”.  It is well-known that male abusers move from one abusive relationship to another.  A colleague Dr. Ron Allanach wrote “In the Caruso case, the Court is proactive, sensing the burden is on the offender rather than the victim; thus, the responsibility for proof that Mr. Caruso has “let it go”, poses no danger to the victim and has done the necessary therapy on his own behavior and to figure strategies to change, rests precisely on the shoulders of the offender where the burden should always remain.” The SJC called the frustration felt by Mr. Caruso the “collateral consequence” of the permanent restraining order put in place initially issued as a result of his threats to kill his former girlfriend.  Time alone and location has no bearing on whether a permanent order is sustained.  No person should live is fear that a former partner is going to appear at her workplace or stand behind her in the line at Starbucks while she thinks about what blend of coffee she might want.

“Substantive decisions about bail or no bail holds will be more reliable by having access to the violent history of domestic violence offenders and the protective orders that have been issued time and time again.” Michael Sefton


Allanach, R. Court is proactive. Personal correspondance. March 2014

Sefton, M. 2014,  https://msefton.wordpress.com/2014/03/11/collateral-consequences-stay-away-orders-that-are-forever/ taken January 21, 2017

Valencia, Milton. SJC rules on Utah man’s permanent restraining order. Boston Globe March 11, 2014, taken March 24, 2017

Behavior regulation and fire: an overlooked sign of inner conflict

WESTBOROUGH, MA March 1, 2017 Playing with fire can be the most dangerous of all childhood behavior and a sinister expression of rage among adults with severe psychopathology. It is often overlooked as an expression of emotional problems among persons of interest with whom the police encounter. Early in my career at Boston City Hospital I was a member of the juvenile arson program that evaluated children who were referred with fire setting as the primary sign of distress.  I worked with Inspector Al Jones of the Boston Fire Department and Dr. Rita Dudley at the Center for Multicultural Training in Psychology (CMTP) at BCH.  Rita was instrumental in growing the program into a regional center for the assessment of juvenile arson.  Inspector Al Jones of the Boston Fire Department was our liaison with front line investigators.  It was a fast paced program that got kids in for assessment and treatment quickly because we knew that some of the children we were seeing were at high risk of repeated fire setting and some were merely curious with their match play.

During my fellowship year I evaluated 49 children who were sent to us by fire departments in the Boston area.  I worked with Dr. David K. Wilcox, a Boston area practitioner and Dr. Robert Stadolnik, then at Westwood Child and Family Services, as key colleagues in my development and expertise in this area of psychology.  Bob published Drawn to Flame, a book about childhood firesetting in 2000.  The key for those of us involved in the program was to identify individuals who were most at risk of repeated fire setting and determine the underlying cause of their immense emotional turmoil.

The expression of underlying anger using fire is a malevolent sign conflict and detachment – sometimes psychosis and delusional thinking.  It represents inner conflict and emotional turmoil as I mention in a post published in 2013. Although quite rare, fire as a symbolic expression of delusions is documented. More commonly though, fire is a signal of emotional dysfunction in the life and family of a child or adult who is suspected of arson.  To what extent it represents underlying trauma requires a comprehensive psychological assessment and careful history. In the most dangerous cases, hospital care is required for the safety of the child or adult with firesetting behavior.  In the adult, arson for hire or an insurance scam represents a large proportion of those arrested for fire-related behavior.

Fire as an expressive behavior

Fire is instrumental in the expression of culture, ritual and is symbolic of great emotion and excitement. Its use at public events, celebrations and parties is commonplace.  People enjoy the dramatic sensory experience associated with seeing and feeling fire.  At what point is it a sign of conflict or burgeoning emotion? The expression of anger may be something as subtle as burning one’s own clothing in a small ceremonial fire in the living room fireplace.  Who would do that you might ask and why?  One example is a person who has lost a large amount of weight may exemplify the accomplishment by burning the larger clothes.  It is a symbolic way of saying goodbye to the old habits that may have caused the weight gain. Ok – that is plausible.  Another person might burn clothing as a way of undoing internalized feelings of shame and self-hatred engendered by early childhood trauma.  Also a plausible explanation of hidden psychopathology that often has deadly results. Some firesetting may represent a preoccupation with flame as an expression of fear and dread coming from exposure to violence within a dysfunctional home. This is a larger subset of persons than one might think and represents a sign of growing emotional lability.

The question for psychologists and police officers is how to identify persons of interest with the emotional coping deficits that place them at risk for using fire as an expression of their feelings and conflict. “The underpinnings of violence are often present in some form or another and may be represented by a marginalized demeanor and extremist views” according to Michael Sefton, Ph.D., Director of Psychological Services at Whittier Rehabilitation Hospital in Westborough, MA.

“The inconsistent and unpredictable exposure to violence contributes to excessive and unpredictable behavior” according to Michael Sefton in a 2013 blog post

The treatment model involves individual and group therapy to assit patients in the identification of inner emotions and feeling states.  I have worked with pediatric patients whose behavior is totally unregulated and unpredictable and yet when you ask them what they were feeling at the time of the fire they cannot tell you. Fire may result in a discharge of emotion like lightning. In the same way some persons are physically abusive – others set fires to release their strong emotions. The current reality suggests that errant use of fire material represents one of the most lethal expressions of underlying emotional turmoil and unbridled conflict in people. There are few programs equipped to understand and treat people with these behaviors and firesetting is often an exclusionary behavior  for entry into treatment programs everywhere.


Sefton, M. Juvenile Firesetting, blog post:  https://msefton.wordpress.com/2013/12/10/juvenile-firesetting/,  taken January 14,2017

Police as therapist: the inherent risk of unconditional positive regard 

WESTBOROUGH, MA January 12, 2017 Changes in the responsibility for those afflicted with major mental illness must remain in the hands of medical and psychiatric providers who are trained in contemporary diagnosis and treatment models. Yet a growing mental health strategy has emerged to train and educate first responders – including the police to deescalate and divert those with mental illness from jails into treatment.  The problem with diversion here in Massachusetts and New England is that a continuum of care is lacking. Since the closure of the state hospital system here in Massachusetts the community-based treatment centers have been overwhelmed by the volume of cases they must see.  To say they have failed is shortsighted and disingenuous and behalf of the Globe Spotlight team.

Make no mistake about it, putting police officers in the place of psychotherapists and psychiatrists is not going to happen here or anywhere. But cops are being asked to act as mediators to diffuse encounters with persons with suspected mental illness. The intention is to reduce violent encounters between the police and those with mental health issues. “Most people with mental illness are not dangerous, and most dangerous people are not mentally ill” according to Liza Gold, 2013. Yet in the past several years there have been many high profile officer-involved shootings involving people afflicted with a variety of psychiatric conditions including major depression raising the specter of suicide by cop.

POLICE ACT AS CRISIS MEDIATORS WITH MENTALLY ILL

It is very risky putting the police in the role of crisis intervention specialists to manage those who may be emotionally distraught. For one thing the high incidence of drug and alcohol intoxication in these cases makes any negotiation or mediation almost impossible. I was always taught that until the patient is sober there is no meaningful assessment or interaction is possible.  Police are the front line responders to crises of all kinds. Asking them to serve in this new role presents a level of officer specialization like never before.  Some officers are being asked to offer unconditional positive regard to those encounters in an effort to slow the scene giving time for intervention to take hold.  In some places like San Antonio, TX and Vancouver, BC it works.  But it has taken a long time to gain traction. If the goal is to avoid incarcerating those with mental illness this is especially difficulty in the absence of a treatment continuum as I have said.  In the cities just mentioned there is a well established mental health infrastructure that affords the police various options for the unstable citizens they are asked to assist.

In most larger communities a dearth of mental health services exist resulting in a large number of mentally ill persons being held in custody – sometimes a county house of correction or any one of

Dr. Michael Sefton brought out myths of mental illness while serving as a police officer retiring in 2015

16 prisons in the Commonwealth of  Massachusetts. The Spotlight team at the Boston Globe has featured the plight of those who are sent to prison with comorbid mental illness and substance abuse. The fact is that criminality and mental health are often difficult to disentangle.

The National Alliance for the Mentally Ill believe as many as 20 to 40 percent of prison inmates may have severe mental illness and may not be receiving the needed treatment to allow them to rehabilitate.  Yet in the absence of the mental health infrastructure needed to provide treatment – including hospital care for those most unstable, few viable options were put forth.

The Boston Globe fails to inform readers that criminality and mental illness are not mutually exclusive.  Drug addicts break into homes to feed the hunger of their addiction.  In prototypic fashion, the Globe offers no alternative and no solution aside from casting blame on the Commonwealth of Massachusetts. Without a doubt the stories they report are heart wrenching and emotionally palpable for the readers. But not all those in custody who are suspected of preexisting mental illness are helplessly suffering without therapy.  Most are not.  In many cases being incarcerated allows an addict to become clean and sober and begin the first steps of recovery. Those who are most resistant to therapy and fail to attend psychotherapy, anger management, and medication monitoring have a higher risk of violence and substance abuse. This fact must be considered when responsibility for treatment failure is studied.  

Those relationships that suppress the normal, effusive, life force are detrimental to health much like a toxin said Sefton in 2013.

ALTERNATIVE SENTENCING

With so many incarcerated persons with suspected mental illness change must be initiated  by having services available to those on the front lines.  The criminal justice system and the department of mental health have an opportunity to work together now that the pendulum once again swings toward a treatment model. The police can be trained to control the scene through intervention and mediation strategies by slowing things down. When charges are brought alternative sentencing models may offer leverage that include mandated treatment in lieu of jail time.  Studies show that those who remain in treatment are less violent than those who fail or drop out of treatment, Torrey, et.al., 2008.

Mental health patient often rely on community services and social welfare including housing, disability payments, medical care and more.  Access to these services may be tied to participation in treatment including psychotherapy, medication, if prescribed, and substance abuse treatment.  Here is Massachusetts M.H. Advocates reject this notion as unfair a response that remains unique across the country.

The interaction of substance abuse and mental illness is complex.  Persons with drug and alcohol addiction must be expected to become sober with the help of substance abuse treatment and family support. The risk of violence and suicide declines when sobriety can be maintained.  The 12-step programs have great success and are free to anyone willing to attend. Family members may attend Al-Anon or some drug-specific family support group.

Mental health infrastructure is necessary for the system to work.  In San Antonio it has taken 15 years to establish a system that works and saves lives.


Torrey, CF et. al. The MacArthur violence risk assessment study revisited: Two views ten years after its initial publication. Psychiatric Services, vol. 59, issue 2, February 2008, pp. 147-152.

New age cops – the future innovation of community policing

WESTBOROUGH, MA December 29, 2016 I have long been an advocate for prompt and comprehensive treatment for those afflicted with mental illness.  Now police are increasingly linking up with mental health agencies as a way of diverting mentally ill person’s from jails into treatment for their emotional affliction.  In my experience this is no easy task.  In some cases criminality and mental illness are not mutually exclusive.  Some who suffer with emotional issues like bipolar depression, drug addiction or anxiety may respond poorly to treatment and may need containment. Those most refractory to treatment often become most difficulty to manage in society.  The untreated mentally ill have a higher rate of violence than those in voluntary treatment.

psychology2As early as 1984, I served the pediatric population in Boston at the Boston City Hospital Pediatric Emergency Department as the on-call clinician in psychology. That same year I was appointed to the ED at Hale Hospital in Haverhill, MA for screening people in crisis.  Those who were stable and had support systems in place would be released – usually with an outpatient referral. Meanwhile, patients without at-home safe guards who could not plausibly answer the question “what brought you to the decision to harm yourself?” were admitted to the hospital.  Other mitigating factors like healthy living arrangements, employment, sobriety, and no history of suicidal behavior were positive indicators of future outcome.  It was a position I loved and is an important clinical role to this day across the United States.  Later as a community mental health psychologist in Long Beach, CA, I served the Children’s Service as someone charged with screening adolescents in crisis living across Los Angeles County. In each of these locations I worked closely with social workers, case managers, police and gatekeepers at state and county psychiatric units to find open beds for kids in need.

In 25 years since there has been very little innovation and fewer still treatment beds for those in need. Today’s depressed and emotionally wounded often spend days in emergency department hallways further wounded by a demoralizing system of delivery that is overwrought and has no place to send them.  This scenario was the case in 1985 and remains the case in 2016.  In Massachusetts and counties across the United States publicly funded hospital beds – including state hospital beds have been eliminated.  In the 1970’s and 1980’s the pendulum of advocacy swung toward community-based care and away from hospital-based treatment.  This left the chronically mentally ill without a support net for treatment, medication management and long range hope.  Many became homeless, unemployable and abusive of drugs and alcohol.

Police provide frontline intervention – often with little training

Police officers became the first line of defense as the hospital beds were eliminated. The mentally ill and those addicted to any number of drugs or alcohol grew homeless and sometimes menacing as they struggle with symptoms. Now police officers are being trained to intervene with these marginalized citizens with crisis management skills.  This poses a conundrum for the current zeitgeist of community policing theory in that the notion of dangerousness relies on critical scrutiny of the underpinnings of human behavior and often nonverbal indices of psychopathology. Some believe this is state of the art police science.  Departments from Augusta, Maine to Los Angeles, CA to San Antonio, TX are using frontline officers as crisis resolution specialists for police encounters with the acutely mentally ill. Many are paired with licensed clinicians while others are working the streets alone.

The collaboration between police and mental health personnel is not new.  But the use of police officers as crisis intervention specialists is innovative and gaining traction in many places around the country. Yet these officers must always be aware of the uncertainty of some encounters with police and those suffering with paranoia or psychotic, illogical delusions, PTSD, or traumatic brain injury that may not respond to verbal persuasion alone.  Decisions about when to utilize greater force for containment of a violent person is sometimes instantaneous.

The use of force must be fluid and officers in the field are expected to modulate the force they apply to the demands of the situation and be ready to respond to changing threat levels.             Michael Sefton, 2015

In 2002, I was appointed to a Massachusetts police department having once served in southern Maine right out of college.  As a psychologist I made an effort to bring mental health concepts into police work without much fanfare or interest.  Mental health topics are not as sexy as defensive tactics or firearm training, I was once told, so finding numbers was sometimes tenuous.  There are still many myths about intervening with those who are making suicidal and homicidal threats and training opportunities are taking on more importance.  Especially these days.  Suicide by cop became a phenomenon that no officer ever wants to confront. All violent police encounters guide officer behavior. “The degree of response intensity follows an expected path that is based on the actions of the perpetrator not the actions of the police” (Sefton, 2015).

Suicide by cop – predicting behavior

In the 2014 FBI Bulletin, Suicide by cop (SBC) is defined as “a situation where individuals deliberately place themselves or others at grave risk in a manner that compels the use of deadly force by police officers” according to Salvatore, 2014.  This happens more than one might expect and is often preceded by rehearsal events according to Salvatore.  “Suicide rehearsals are practice for the attempts that will follow within a few hours or days. SBCs may be tested. Officers should use caution when recontacted by an individual who previously presented signs of mental illness, had no need for assistance, was standoffish when asked what was needed, or was anxious to assure the officers that everything was fine. The initial contact may have been practice for an SBC.”

The best predictor of behavior is past behavior.  The prior demeanor that police have observed in those frequent flyers who pop up on police radar over and again often sets the stage for violent conflict later on. But not always.  Situations grow exponentially more grave in the presence of drugs and alcohol raising the level of lethal unpredictability. For many struggling with depression or other serious mental illness being sober or drug free can be the healthiest thing they can do for themselves.  The uncertainty of the SBC scenario makes the likelihood of a successful de-escalation a tenuous exercise in the life and death force continuum.

The motives for SBC are multifactorial and undeniably linked to poor impulse control associated with drug and alcohol intoxication.  The triggers are identified by Salvatore as “individuals who feel trapped, ashamed, hopeless, desperate, revengeful, or enraged and those who are seeking notoriety, assuring lethality, saving face, sending a message, or evading moral responsibility often attempt SBC”(2014).  Some believe they will become famous and earn large monetary settlements for their surviving families following a SBC scenario.  Other victims are tortured souls who make no demands and offer no insight into their suicidal motive and are killed when they advance on police or turn a weapon toward responding officers.

Training in police-mental health encounters has slowly taken hold.  This innovation in community policing offers hope for reducing fatal encounters.  No amount of training in crisis management will reduce incidence of SBC to zero but ongoing training to identify the behavioral indices of imminent violence, psychosis, and suicidal/homicidal ideation will reduce these lethal encounters.  Most officers are highly skilled at using their verbal skills to de-escalate a violent perpetrator without using lethal force – even when a higher level of force may have been warranted.


Salvatore, T. (2104), Suicide by Cop: Broadening our Understanding. FBI Law Enforcement Bulletin, September. Taken 12-29-16 Bulletin website https://leb.fbi.gov/2014/september/suicide-by-cop-broadening-our-understanding.

Sefton, M (2015) Blog post Law Enforcement- Mental Health collaboration. Taken 12-28-16, https://msefton.wordpress.com/2015/11/27/law-enforcement-mental-health-collaboration/