WESTBOROUGH, MA July 16, 2017 In last weeks publication I introduced the problem of mental health and co-occurring substance abuse with some ideas about alternative restitution and treatment. These involve greater discretionary awareness among police officers. More importantly options to jail require viable alternatives that will end the revolving door of minor criminality coupled with treatment for the breadth of addiction seen on a daily basis by law enforcement.
Mental and Physical Health Screening
At time of arrest the individual must have some level of mental health assessment if mental illness is suspected or documented. When I was a police officer prior to 2015 we often asked the D.A. to provide a court clinic assessment of the suspect to rule out suicidal ideation or delusional thinking. This must also include a screening for dangerousness especially when a subject is arrested for intimate partner abuse. Next a health history questionnaire should be undertaken to screen for co-occurring illness – both physical and mental. If a diabetic suspect is held without access to his insulin he is at great risk of death from stroke. Similarly, a person arrested for assault who suffers from paranoid ideation is at greater risk of acting violently without access to psychiatric medication. Finally, an alcoholic brought to the jail with a blood alcohol level greater than 250 is at great risk for seizures and cardiac arrhythmias when delirium tremens begin 6-8 hours after his last drink. The risk to personal health in each of the scenarios above must be taken seriously and the obtained data should be factually corroborated. Police departments across the United States are pairing up with private agencies to provide in-house evaluation and follow-up of individuals who fall on the borderline and may not be easily discerned by the officer in the field.
Diversion Safety Plan
Next, the probation and parole department must obtain an accurate legal history prior to consideration for bail. A nationwide screen for warrants and criminal history based on previous addresses is essential. In many places these are being done routinely. In the case of someone being arrested for domestic violence he may have no convictions thus no finding of criminal history. For these individuals the dangerousness assessment may bring forth red flag data needed for greater public safety resulting in protection from abuse orders, mandated psychotherapy, and in some cases, no bail confinement when indicated. Releasing the person arrested for domestic violence without a viable safety plan increases the risk to the victim and her family, as well as the general public – including members of law enforcement.
Bail, Confinement, Mandated Treatment
There is some thinking that higher amounts of bail may lessen the proclivity of some offenders to breach the orders of protection drafted to protect victims and should result in revocation of bail and immediate incarceration when these occur. I have proposed a mandatory DV Abuse Registry that may be accessed by law enforcement to uncover the secret past of men who would control and abuse their intimate partners. This database would also include information on the number of active restraining orders and the expected offender’s response to the “stay away” order. In cases where the victim decides to drop charges there should be a mandatory waiting period of 90 days. During this waiting period the couple may cohabitate but the perpetrator must be attending a weekly program of restorative justice therapy and substance abuse education. Violations of these court ordered services are tantamount to violation of the original protection order (still in place) and victim safety plan and may result in revocation of bail. If the waiting period passes and the perpetrator has met the conditions of his bail than he may undergo an “exit” interview to determine whether or not the protection order / jail diversion plan may be extended.
In many jurisdictions the mentally ill cannot be forced to take medication nor can they be forced into treatment. Adherents to this belief advocate on the behalf of the chronically mentally ill for the right to make these individual choices – treatment or no treatment. Ostensibly advocates seem unconcerned for the public health risks associated with ongoing drug addiction and major mental illness. There needs to be an active system in place to provide guardianship to individuals with repeated failed treatment that mandates treatment for those who cannot remain in a program of sobriety and psychotherapy in lieu of incarceration. In many cases a family member may be appointed temporary guardian for up to 180 days that allows decisions to be made about patient care up to the guardian not the patient himself who may be unable to stay on track.
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.
WESTBOROUGH, 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,
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
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.
San Antonio, TX – February 25, 2017 Police officers wear many hats these days. I have spent the last few days learning about a specialized police unit in San Antonio Texas with the SAPD. The Mental Health Unit is a small, well-trained group of police officers who have committed themselves to the positive interaction of police officers and citizens with presumed mental illness. These police officers have a unique window into the chaos some families experience and the opportunity to bring calm to crisis (Sefton, 2014). In many cases, the correct response to this dysfunction should include a follow-up visit in the aftermath of the initial call when the dust has settled from the crisis that brought police to this threshold. When this is done it establishes a baseline of trust, empathy, and resilience. It works and I have seen it for myself.
Over a 15 year span the SAPD has established relationships and built a continuum of service whose mission is jail diversion and treatment for those who are afflicted with mental illness and substance abuse. The Restoration Center in downtown San Antonio is the nucleus for this “smart justice” model. It includes a mobile crisis outreach, 48 hour hospitalization, if necessary, a 90-day homeless shelter with job training e.g. resume building and job interview clothing, childcare and apartment units for those who qualify. As subjects move through the continuum they are provided referrals for individual psychotherapy, substance abuse education, Alcoholic’s Anonymous and the range of 12-step recovery programs. And everyone working there buys in.
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. Michael Sefton blog post 2013
I was given the complete tour and introduced to some key players including Ms. Amanda Miller coordinator at the Mobile Outreach program. The experience was enriching and illustrated the range of possibilities of humane care for those most vulnerable and often incompetent to make healthy choices for themselves. I wasn’t sure what to expect but I came away wishing I could have stayed on longer. The project diverts citizens into treatment in lieu of incarceration and also serves as an in-house resource where brother officers can turn when times get tough. And the mental health unit has seen its share of despair and self-destruction on their side of the blue line with sometimes insufferable results.
Police officers’ department-wide are trained in techniques of crisis intervention by the same two officers I was fortunate enough to ride with. For years, too many emotionally troubled citizens wound up among the incarcerated criminal population in state and county jails and did not receive the care they needed. In Bexar County, Texas, which includes San Antonio, with a growing population of over 1.5 million the main jail now has 800 open beds where it was once filled to capacity.
“CIT provides police with all kinds of useful resources. And when combined with adaptive strategic thinking, access to mental health professionals, and good leadership and good culture around applying the lessons of CIT, it can save lives,” said David M. Perry, an associate professor of history at Dominican University in Illinois and a journalist who has written about police violence and disabilities recently cite in a CNN story written by Liza Lucas in 2016.
San Antonio and over 22 communities share the services of the Restoration Center in downtown San Antonio
Culpability and Mental Illness
Are those with mental illness culpable for their behavior? Technically they are responsible unless determined to be unable to discern right from wrong based upon their mental incapacity. Does the fact that they suffer with conditions like bipolar depression, schizophrenia, or drug addiction render them not responsible? There is a national trend to view those with active mental illness as “not responsible” for their behavior largely due to the common belief that if the mental illness were being treated than the criminality in which they may be embroiled would plausibly diminish. Whenever something sensational happens like a school shooting or some other senseless criminal act people universally remark “he was sick” or “she must have been out of her mind” to do that. Not so fast say the social scientists where as the true prevalence of diminished capacity is quite rare.
I strongly believe that mental illness does not exempt citizens from responsibility for crimes they commit. I agree that alternative sentencing may be a powerful tool to bring these individuals into treatment. The substantive goal of streamlining encounters between police officers and citizens who suffer with untreated emotional problems belies the mission of these gifted officers and can teach others the role of discretion in mental health encounters. The reason for this is to deescalate potential violence and thereby reduce the incidence mentally disturbed persons who wind up in jail. This speaks to the importance of getting those most in need into treatment and off the streets sometimes by having a judge mandate they enter treatment. When charges are brought forth alternative sentencing models may offer leverage that include mandated treatment in lieu of jail time know as alternative sentencing. Studies show that those who remain in treatment are less violent than those who fail or drop out of treatment, Torrey, et.al., 2008. In Massachusetts where I served as a police officer for 12 years too many myths entangled the process of accessing treatment for the mentally ill. Officers were sometimes unsure of their options when a Q-5 prisoner was brought it and rarely made referrals for mental health care. Q-5 is the nomenclature used when referring to someone with a history of mental health issues – usually suicidal threats. These prisoners were required to be on one to one supervision when held in jail. At least that was the myth at the time I was serving.
Community Policing and Aftermath Intervention
I learned several important things about police officer interaction with citizens having mental illness. It is a complex and time consuming endeavor that requires follow up in the aftermath of a crisis. Police officers build credibility and trust in the process of this community interaction with citizens and those in the treatment continuum like physician Roberto Jimenez, M.D., a psychiatrist who has been there from the beginning in Bexar County. Dr. Jiminez began his career in Boston at the once revered Boston City Hospital where I completed my postdoctoral fellowship. He said to me “we had the national model in Boston….” referring to the system in place for police-mental health interaction in 1980. At the time, his service was utilized in conjunction with the state department of mental health and an active system of neighborhood health centers throughout the city. He referred to himself as the police psychiatrist. By then, the Massachusetts state hospital system had been deconstructed and was no longer in the continuum of care. The chronically ill fell off the treatment radar. Importantly in Massachusetts, this triggered the swing away from hospital-based care to the community health centers who became the front line for those in crisis. At this point the myth of mental illness began its insidious transformation and jail became the containment locale in the absence of the venerable state hospitals. In January 2017, Massachusetts Governor Charlie Baker expanded number of available beds at the Bridgewater State Hospital for care of those in crisis.
Officers in the SAPD Mental Health Unit undergo specialized training in crisis intervention. Officers Stevens and Smarro teach the 40-hours class to police officers from across the country. All police recruits in the SAPD academy are given this training as part of their early law enforcement education suggesting strong support from the command hierarchy. Importantly, the CIT model teaches officers to return to the scene of their calls to make referrals for care as I observed in February. The follow-up call is key in rebuilding trust and illustrates the commitment in police-mental health care continuum. Just as importantly is the relationship created among police officers and direct service personnel like Dr. Jimenez who share the understanding of what can be done for those most in need.
Ostensibly, building relationships with network psychotherapists, physicians, addiction specialists, court judges, and other support service like Child and Family Services is essential. Officers Stevens and Smarro spent hours on the telephone reaching out to the network of physicians, judges, hospital admission personnel and brother officers all in the service of a single case they picked up one evening while on an overtime patrol shift. Had they not caught the call on that night the complainant family may have flown under the law enforcement radar forever and a 33-year old depressed and delusional male may have become increasingly morose perhaps violent. Instead he was put into treatment with the real eventual possibility of receiving social security disability payments to help he and his family and the treatment he needs to begin life again. Next is a strong conviction in what you are being asked to do. It is necessary and constitutive work that often flies below the radar and out of the headlines. It requires patience, flexibility and the right temperament. And finally, officers need to follow-up on calls and build bridges and trust with those they serve including members on the same side of the thin blue line.
Setting the San Antonio program apart is the routine followup in the aftermath of high intensity calls such as domestic conflict or the run-of-the mill calls to houses where families are struggling with under employment, substance use or any number of social problems. A brief second or third visit may just do the trick to hook in a family or individual otherwise in the margins of society bringing forth growth and human contact.
Perry, D. 2016. Changing the way police respond to mental illness. http://www.cnn.com/2015/07/06/health/police-mental-health-training/
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
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.
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.
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.
As 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.