Discretion, Treatment and Alternatives to Jail

PART 2

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.

Guardianship

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.

 

 

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,

lakefoll0916_kc01-250x250
Dr. Sefton discussing psychological autopsy of Steven Lake with coauthor Brian Gagan (left)

Maine Homicide-Suicide in 2011.

Co-occurring Illness: Effecting change at times of crisis

stream_img 

Google images

 

WESTBOROUGH, MA  – April 24, 2017 There is no magic solution for de-escalating someone who is in “crisis” or emotionally distraught.  The loss of control may signal a failure of reality testing that can signal a diminished capacity to appreciate the consequence of their behavior.  This occurs frequently when people who have mental illness have co-occurring drug and alcohol addiction. It is true that the correctional system has more than its share of mentally ill prisoners but for many being in jail is the only way to stay sober.  The full capability to provide mental health services in the correctional system here in Massachusetts has not been realized.  The courts are reluctant to require that someone receive treatment for mental illness and/or substance abuse in lieu of going to jail.

Criminality and mental illness are not mutually exclusive so there will always be a high number of incarcerated persons with chronic underlying psychiatric diagnoses.  The prevalence of mental illness in the general population may range from 5-15 percent. The degree of mental illness in the correctional system may be as high as 40 percent by some accounting but the number is misleading. One needs to consider treating mental illness when it becomes a barrier to functioning such as in schizophrenia or bipolar depression where the symptom profile interferes with reality testing. Only then may a contract for treatment may be constructed to include medication and psychotherapy depending upon the diagnosis.  In cases where mental illness and co-occurring substance abuse exist a determination about primary diagnoses and treatment options must be considered.

“The consequences of dual diagnosis include poor medication compliance, physical comorbidities, poor health, poor self-care, increased risk of suicide or risky behavior, and even possible incarceration” according to Buckley and Brown, 2006

In many cases of emotional crisis those in need can be diffused with recognition of their struggle – such as death of family member or loss of employment.  By showing empathy for their emotional burden police officers and mental health providers can intervene and make a real difference.  But effecting change takes time and a consistent message that personal responsibility begins at home.  Instead of placing blame on a “system” that is filled with holes individuals need resilience and family support to get the help they require. teachinginprisonBefore I am criticized for being insensitive, I point to the 12-step programs in alcohol and drug recovery.  They are free and in many cases provide 24-hour support and mentoring at times of crisis. I strongly believe that if people can remain clean and sober than the need for crisis intervention will decrease.  Ostensibly, this is a perfect first step toward recovery and will bring forth a palpable reduction in emotion and reduce the potential for violence.  When substance abuse is stopped emotional growth is more able to take hold.  Healthy, more effective problem solving may result from prospering emotional maturity allowing for resilience and enhanced coping.

Stress can engulf individuals and families for a variety of reasons and should not be judged. People cope with stress differently and in many cases achieve emotional relief by having someone to talk to.  Some clinicians believe great personal change may be possible when coping skills are most frail.  But in too many instances, drug and alcohol abuse present a confounding variable when working with person’s diagnosed with mental illness. At the same time this raises the risk to law enforcement exponentially. Why?

One response to stress is the increase in substance use and with that increase there is often a worsening of any underlying mental health disorder such as depression and anxiety.  “There could be a common factor that accounts for both, primary psychiatric disorder causing secondary substance abuse, primary substance abuse causing secondary psychiatric disorder, or a bidirectional problem, where each contributes to the other.” (Buckley and Brown, 2006) Unemployment, early childhood trauma, financial burdens, and random emotional baggage result in a range of actions that foreshadow regression and failure of coping mechanisms that put us all at risk.  Some people are able to endure extreme levels of stress with little to no outward sign of distress while others boil over at the first sign of conflict or emotional ripple.

JAIL DIVERSION

There is a growing push toward alternative restitution and jail diversion for those with mental health and substance abuse problems.  In San Antonio, TX, the Bexar County jail had been filled to capacity for many years.  As a jail diversion and mental health program evolved the population dropped by 20-25 percent from 5000 inmates to 3800.  Data suggests that over one quarter of all prisoners may experience mental illness or substance dependence/abuse and are not receiving treatment.  But here in Massachusetts the systems are not available to make this innovation an effective reality in any scale.  Many departments are using jail diversion options such as drug treatment and counseling but here in Massachusetts psychiatric treatment cannot be court mandated. Arrest may not be indicated simply because a person is in crisis but those in crisis may be involved in some type of criminality such as assault, criminal threatening, domestic violence and property crimes. So what options are available? The drop out rate for patients suffering from major mental illness is quite high. They often stop taking prescribed medication and do not attend counseling sessions.

MENTAL ILLNESS, CRIMINALITY AND RESTORATIVE JUSTICE

bigstock-Mental-illness-in-word-collage-072313As a police officer I found jail diversion a discretionary tool that was used a great deal. Nevertheless there are times when arrest is the proper course of action but jail diversion remains a possible negotiating point for those charged with some crimes.  The correct response to intimate partner violence should include aftermath follow-up and intervention when the immediate crisis has settled from the events that brought police to this dangerous threshold. Arrest is mandated by state statute when one spouse has visible injuries. Whenever possible using a restorative justice model – often limited to incarcerated individuals – may allow those arrested for crimes against persons to reconstruct their encounters with police and gain concrete understanding of events and the impact substance abuse may have had on the actions taken by themselves and law enforcement. Some never attain empathy for victims, family members including action taken by police and wind up behind bars.  Police encounters with persons having co-occurring mental health and substance abuse are frequently violent and often result in charges for assault on a police officer and more. In the aftermath of these encounters offenders may be sent to treatment in lieu of formal charges with the understanding that sobriety and psychotherapy are indicated.  In cases of treatment avoidance police have the option to file charges later on.

Techniques for understanding mental illness may facilitate mutual understanding and establish the needed bridge to facilitate treatment as published in 2015 (Sefton, 2015). Those seeking diversion from incarceration must demonstrate the willingness to change and take responsibility for their actions.  The relationship between law enforcement and community agencies is one that requires a strong foundation and mutual understanding of the framework for reducing recidivism, criminality, and managing mental illness.


Buckley, P. F., & Brown, E. S. (2006). Prevalence and consequences of dual diagnosis. The Journal of clinical psychiatry, 67(7), e01-e01.

Sefton, M. (2015) Emotionally distraught – nearly one-quarter of all officer-involved shootings go fatal. https://msefton.wordpress.com/2015/07/01/emotionally-distraught-nearly-one-quarter-of-all-officer-involved-shootings-that-go-fatal/. Taken March 5, 2017.

Police as crisis interventionist: CIT as it is meant to be

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

mental-health-squad
SAPD Officer Ernest Stevens PHOTO Jenny Snow Kaiser Health News

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

img_6995
Michael Sefton with SAPD-  officers Ernest Stevens (center) and Joseph Smarro (right)

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.


REFERENCES

Perry, D.  2016. Changing the way police respond to mental illness. http://www.cnn.com/2015/07/06/health/police-mental-health-training/

Sefton, M. 2014 Aftermath Intervention: Police first to the threshold. https://wordpress.com/post/msefton.wordpress.com/599

Sefton, M. 2017 Police as therapist: the inherent risk of unconditional positive regard. Blog post. https://msefton.wordpress.com/2017/01/16/

Torrey, CF et. al. 2008. 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.

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/

Scene safety: crisis management and police training

 

WESTBOROUGH, MA  January 7, 2017 What happens once the “scene is safe”? Usually the hostile threat is taken into custody – either to jail or a hospital. In the aftermath of high stress events such as talking a violent alcoholic into surrendering there should be an opportunity to follow-up and bring closure.  In the time it takes to defuse a potentially lethal citizen encounter the police officer has established a connection – however slim it may be.  Aftermath intervention may go a long way to further validate the first steps taken with the initial encounter.  With such high incidence of polydrug abuse the threatened violence may take on a surprisingly banal theme and the importance of sobriety may be realized once the scene is safe.

Most officers are already 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.

I have been called to the same home over and over when a violent adult male became intoxicated and gradually overwhelmed and depressed.  Each time officers went to the residence there ended up being a fight.  We deployed OC spray on more than one occasion each of us getting the pepper in our eyes.  This man was hooked up and sent to the hospital time after time. Upon his return (usually within 1-2 days) he would have a short period of sobriety and slowly start drinking and abusing his father again resulting in the same battle we had days, weeks, months ago. Interseting to me was that the younger man was quite reasonable when he was sober. He had no interest in seeing a therapist – nor could he afford one.  The important question to me was what steps could be taken to link this guy to a 12-step alcohol (and drug) recovery program? There were meetings in our town and they were free.  I thought if he could meet a sponsor than hs abuse of his father might be reduced.  In any case, sooner or later someone was going to get seriously injured on a call at this home.  We had heard rumors of him wanting to commit suicide by cop.

Community policing has long espoused the partnership between police and citizens said Sefton in December 2013.  The positive benefits to this create bridges between the two that may benefit officers at times of need – including the de facto extra set of eyes when serious crimes are reported. The same goes for crisis management.  The relationships you build while in the community can serve to help soften the scene and slow down an escalating person of interest who may be looking for a fight.  Violence often occurs after a period of brooding isolation that is fueled by alcohol and a bolus of rage.

Police officers are regarded as the front line first responders to family conflict and DV.  Now they are being trained to better interact with those thought to be mentally ill.  For better or worse, the police have an opportunity to effect change whenever they enter into the potentially hostile foray.  This affords them a window into the chaos and the opportunity to bring calm to crisis.