Police and the Mentally Ill
UNABRIDGED VERSION OF “RETHINK CRISIS RESPONSE,” Reason October 2020
Summary: There are some good models for responding to people in the midst of mental health crises – either with better trained police or no police at all. But the rate limiting variable in reducing these encounters in the first place, which is the ultimate goal, is a serious political commitment to fixing the system responsible for caring for people with severe mental illness in the first place.
“Please just send one police car, please don’t have your weapons drawn, please take them to the hospital.” These are the words that many families with a mental ill loved one have learned to say when crisis strikes. Sabah Muhammad and her siblings have spoken them several times since 2007, the year her brother developed paranoid schizophrenia. A standout student and star running back at his high school outside of Atlanta, her brother started crawling into himself around the time of his 18th birthday. “He would become catatonic, barely moving, just staring into space. Sometimes he locked himself in his room for weeks, refusing food except to come out of his room at 3 am to make toast that he blackened to carbon ‘to get the poison out,’” Sabah told me.
Mute and malnourished, he would not allow family to take him to a psychiatrist but he desperately needed help. So Sabah and her family had to call the police — and prayed each time. The data justify her dread. Between 25 and 50 percent of all people killed annually by police are in the midst of mental health crisis when they are slain, according to a report by the Treatment Advocacy Center. Nationwide, a person with a psychotic illness is 16 times more likely to be killed during a police encounter than a person without such a condition. Far more often than death, the consequences of ill-fated encounters are violent confrontations, arrests, and incarceration.
Police are often the first responders because there is no one else who can attend to a person in crisis. “I don’t think we have any option but to be social workers, marriage counselors, coaches,” Joann Peterson, a retired New Haven police captain, told the Connecticut Mirror. At the same time, having police on the front line wastes community resources, overburdens law enforcement and, when things go badly, criminalizes severe behavioral disruption due to illness.
The answer to such tragedies seems obvious: reduce encounters between police and people with mental illness or, at least, change their nature. “Cop culture has always been, ‘We’re the people who respond to a crisis, jump out of the car, and take immediate action’,” says New York Police Department Chief Matthew Pontillo. “And we’re saying no, that’s not the correct paradigm anymore.” While wholesale replacement of police officers with social workers is unrealistic, there are police-based programs that respond humanely to people who are in crisis and usher them into care.
The best-known program is Crisis Intervention Team, CIT, training for police. The 40-hour program was created by authorities in Memphis, TN following the tragic death of 27-year-old Joseph DeWayne Robinson in 1987. Robinson’s mother called the police as her son threatened suicide while cutting himself with a large knife, inflicting over one hundred wounds on his body. When police came on to scene, Robinson reportedly lunged with the knife and they fired. According to some accounts, Robinson was high on crack; others said he had paranoid schizophrenia; together or combined, these states could make someone psychotic and agitated.
The disaster spurred the city of Memphis to develop a system for diverting people with mental illness from the criminal justice system to treatment. The Memphis Model of crisis intervention team training has three parts. The first is 40 hours of training in mental health for self-selected police officers — often, it turns out, those who have a mentally ill relative. The idea is that these trained officers have elite status. The second part entails clear lines of communication so that the specialized CIT is dispatched to a mental health emergency. The third component is a centralized mental health facility with guaranteed acceptance policy where the police can bring the distraught individual. Today, there are 2,700 CIT programs, accounting for about 15 to 17 percent of all police agencies in the country.
During CIT training, officers learn to recognize tense situations and defuse them by not confronting people, yelling directions, or making quick movement. The general idea is to “slow the situation down,” keep people from feeling cornered or under threat. To reduce tension, Tucson police on the CIT, for example, do not wear uniforms and drive unmarked cars. Officers are trained to recognize the signs of psychosis and suicidal despair. They learn about posttraumatic stress disorder and extreme reactions to drugs, such as PCP or methamphetamine, which can produce intense agitation or paranoia. They understand that people with schizophrenia or who are manic may be responding to hallucinations or refuse to cooperate with police requests because voices tell them not to.
A hybrid version of the crisis intervention team operates through the Fire Department. In Spokane, Wa., for example, the EMS workers called to a scene can request that a mental health worker make a follow-up visit and a social work student from Eastern Washington University School of Social Work students will visit and connecting the client with community resources. Elsewhere in Washington State, the Tacoma Fire Department and Tacoma Police Department have partnered to coordinate a crisis response system which sends out mental health providers by themselves or with an emergency technician or a police officer. Last year, the Tacoma Fire Department became the first fire department in the nation to become a licensed behavioral health agency.
Perhaps deployment of a CIT-trained officer could have prevented the death of George Zapantis of Queens this June. The 29-year-old man, who suffered from bipolar illness, was wielding a large sword in his mother’s basement. Reports conflict as to whether he had the sword in hand when officers came to the home, but they tased him multiple times and he died of a heart attack. Perhaps a different response would have save Tony Timpa, 32, who called Dallas police himself from a parking lot. Off his anti-psychotic medication, Timpa feared he was a danger to himself. Police arrived to find Timpa already handcuffed by security guards of a nearly store, yet, in a sickening foreshadowing of George Floyd’s death, they had him lie face down and one pressed a knee into his back for 13 deadly minutes. Or perhaps police wouldn’t have fatally shot 29-year-old Osaze Osagie who had schizophrenia and was autistic. When officers arrived at his apartment near Penn State, at the behest of his worried family, Osagie bolted out the door holding a knife; in the chaos, one of the officers opened fire.
Data on CIT training offer mixed reassurance that these tragedies would have ended differently. A 2014 meta-analysis revealed no differences in arrests or use of force between officers who were and who were not trained and a 2019 review of research found rampant variability within training programs; another analysis found that time spent in training ranged from 8 to 40 hours. In New York City, where half of the police force has undergone 40-hour CIT training since 2015, sixteen people with mental illness were killed in encounters with law enforcement, exceeding the number killed prior to initiation of training.
The problem, scholars conclude, is poor fidelity to the three-part Memphis Model. When CITs operate within small regions with close adherence to the parameters– most notably, when paired with fortified community-based mental health services exist – they tend to be more effective than those deployed in larger sites. San Antonio, for example, built a “Restoration Center” crisis center for psychiatric and substance abuse emergencies and a 22-acre campus for short-term inpatient stays, detox units, a medical clinic. Police were then able to divert more than 100,000 people from jail and emergency rooms to treatment between 2008 and 2016, resulting in savings of nearly $100 million.
Miami-Dade is a large county that was able to follow the tripartite exemplar. All shootings declined by 90 percent since CIT training was implemented in 2010 and millions were saved, but the program accomplished something more: it shined a light on the high incidence among police of depression and suicide. According to Judge Steven Leifman, who established the Miami-Dade program, officers who go through the training “have been more willing to recognize their own stress [and] reach out to the program’s coordinator for mental-health advice and treatment for their own traumas.”
Other cities deploy crisis teams that are solely mental health based; police are not part of the first line at all. One of the nation’s longest-running examples is CAHOOTS—Crisis Assistance Helping Out On The Streets. It was created 31 years ago as part of an outreach program of the White Bird Clinic in Eugene, Ore., once a counter-culture medical clinic founded in 1970 as a refuge for “hippies” on LSD trips and other drug-taking youth. Calls for help are routed to staff 24-7 by the local 911 dispatcher. A medic and a mental health professional respond as a team to incidents such as altercations, overdoses, and welfare checks. They wear jeans and hoodies and arrive in a white van stocked with supplies like socks, soap, water, and gloves. Should a situation spin out of control, they call for CIT-trained police back-up, though last year only 150 out of 24,000 field calls made by teams required back-up. People who need further attention are taken to a crisis care facility operated by mental health department. No trips to jail or overflowing emergency rooms.
Mental health teams can bring some much needed relief to municipal budgets – but the model won’t work in jurisdictions with mental health agencies that refuse to send their staff into the field to do crisis work without police accompaniment. This point is frequently overlooked in much of the enthusiastic coverage of CAHOOTS. According to TAC, police officers across 355 law enforcement agencies spent slightly over one-fifth of their time responding to or transporting people with mental illness to jail or psychiatric emergency room. In 2017, they logged in a remarkable 5.5 million miles (or 217 trips around the world) at a cost of $918 million. Multiple studies show that they can reduce jail days and emergency room visits and decrease inpatient hospital stays when they also provide housing and healthcare support. The Eugene CAHOOTS flagship program operated on a $2-million budget in 2019 and saved the locale about $14 million in costs of ambulance transport and emergency room care. Within the year, a number of cities such as Durham, North Carolina, San Francisco, Los Angeles, and New York City, will be launching CAHOOTS models.
The best crisis intervention programs help reduce the toll of police involvement gone awry, but the only way to take encounters out of the hands of police in all but the most dangerous instances is to repair the mental health system itself, the notoriously tattered network of therapists, psychiatrists, hospitals, residential settings, and support services. For a glaring manifestation of the failure, look to the criminal justice system. In 44 states, a jail or prison holds more mentally ill individuals than the largest remaining state psychiatric hospital. A person with a severe condition, such as schizophrenia and bipolar disorder, is 10 times more likely to be in a jail or prison than a hospital bed.
To keep ill people from lapsing into crisis in the first place, improvement across a number of domains in mental healthcare is essential. For one, the gap-ridden system needs extensive repair. An excellent though under-funded model operating in all states is the Certified Community Behavioral Health Centers. The Medicaid-funded demonstration project offers an array of tightly linked services including 24-7 crisis care, psychiatric and medical care, family counseling, and social services. Second, clinicians must engage in more field work. Assertive Community Treatment, ACT, teams plan and monitor treatment. These popular but under-resourced teams effectively embrace patients: accompanying them to medical appointments, representing them at hearings, and helping them manage medication as well as money, applying for services, and aiding them in maintaining low-level employment.
Third, more hospital beds are in critical demand. Since 1960, over ninety percent of state hospital beds have been eliminated and Medicaid has never covered care for mentally ill individuals ages 21 to 64 in a facility with more than 16 beds, if at least half are dedicated to mentally ill patients. This exclusion should be reversed.
Fourth, law and psychiatry need to leverage existing strategies for getting and keeping the most fragile people in care, especially those who refuse to seek help. Assisted Outpatient Treatment, AOT, is a form of civil-court-ordered community treatment aimed at individuals who have a well-established pattern of falling into a spiral of self-neglect, self-harm, or dangerousness when off medication. Studies show AOT to be clinically effective (lower rates of re-hospitalization, arrest, re-arrest, incarceration, homelessness, violence and suicide in participants) and cost-effective.
Finally, civil commitment laws need to be amended. In the case of Sabah Muhammad’s brother, the only reason that her family had to call the police is because Georgia is one of seven states that retains an outdated standard for involuntary care: it requires that danger to self (her brother) or others be “imminent.” Under that standard, police must be on the scene. A different standard, which does not displace the imminent regime, is called “need for treatment.” Adopted in 20 states already, it has a lower threshold for involuntary care and does not require involvement of law enforcement. (Sabah recently began work as Legislative and Policy Counsel at TAC to help lobby for changes to mental health law and policy.) A need-for-treatment standard would give her brother, and others like him who are not in “imminent” danger, better odds of a safe encounter with rescue personnel and an opportunity for families to intervene before their loved ones spiral into an abyss.
Balancing the proper role of police officers– as guardians versus warriors — is now a subject of intense national debate. The mounting public sentiment towards a dominant, albeit not exclusive, ethos of trust and protection should find its fullest expression in the duty to help those who are mentally ill or emotionally disturbed. The shift in opinion, which is also taking place within law enforcement, is encouraging. Good crisis models can show the way, but changes in police training and culture, even removing them from the orbit of first responders altogether, can only go so far without significant advancements in quality and integrity of the mental health treatment system.
Sally Satel MD is a resident scholar at the American Enterprise Institute and a visiting professor of psychiatry at Columbia University’s Irving Medical Center.