1. Sofer, Dalia


Reconsidering how police respond to people with mental illness.


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According to a Washington Post database, approximately 1,400 of the more than 6,000 people in the United States fatally shot by on-duty police officers since 2015 were known to have a history of mental illness. People with untreated, severe mental illness are involved in at least 25%-and up to half-of all U.S. fatal police shootings. Those who have untreated mental illness are 16 times more likely than other civilians to be killed during a confrontation with the police.

Figure. Los Angeles ... - Click to enlarge in new windowFigure. Los Angeles County officials and mental health team members debut the Therapeutic Transportation Pilot Program, a new, unarmed model of emergency response. The program uses state-of-the-art vans, like the one shown here, to transport people experiencing a mental health crisis to a location where they can be stabilized or connected to care. Photo courtesy of the Los Angeles County Department of Mental Health.


Although ill-fated encounters between law enforcement and people with mental illness have received more media attention in recent years, the factors leading to the current situation are complex and long standing. According to a report by Emory University's Blue Ridge Academic Health Group, asylums for people with mental illness were created in the late 19th and early 20th centuries. These facilities were designed to be separate from acute care hospitals and located in rural areas because of the social stigma associated with mental illness and "not in my backyard" views. In 1946, to meet an increased demand for mental health services following World War II, the newly founded National Institute of Mental Health shifted the care of the mentally ill to the outpatient setting.


Nearly two decades later, the Community Mental Health Act of 1963 reinforced this shift, redirecting the care of the mentally ill to community mental health centers and prompting the deinstitutionalization of people with severe mental illness. According to a 2017 report from the National Association of State Mental Health Program Directors and the Treatment Advocacy Center, the number of inpatient psychiatric beds in the United States diminished from 337 per 100,000 people in 1955 to about 30 per 100,000 people in 2014.


But the proposed shift to community-based care did not fully materialize, according to a 2016 Treatment Advocacy Center report, which notes that this has led to a revolving door of hospitalizations, whereby psychiatric patients are discharged quickly to make room for other patients, only to be readmitted weeks or months later. In their report, researchers at the Blue Ridge Academic Health Group point to the varied obstacles currently making it "difficult, if not impossible" for people with mental illness to receive adequate and timely care. Barriers such as too few inpatient beds, inadequate reimbursement, and a lack of trained health care professionals are compounded by a rise in suicide rates, the opioid epidemic, and more people diagnosed with behavioral health conditions such as depression and anxiety.



Within this fragmented landscape, police officers have for decades been tasked with addressing emergencies involving people with mental illness. Increasingly, in an effort to diminish the frequency of violent and fatal encounters, police departments have been instituting crisis intervention training programs to better train officers to engage with people who have mental illness, often in collaboration with mental health professionals and other service providers. Now used in more than 2,700 communities nationwide, crisis intervention training programs are based on "the Memphis model"-a police department crisis intervention team developed by a Memphis, Tennessee, task force in 1987 following the killing of a mentally ill Black man by the police. The aim of these programs is to train officers to become more fluent in areas such as mental health diagnoses, psychiatric medications, substance abuse, mental health law, cross-cultural sensitivity, and verbal deescalation skills.


These programs also create partnerships among officers, mental health professionals, hospital emergency services, and people who are mentally ill and their families. In Eugene, Oregon, for example, the Crisis Assistance Helping Out on the Streets program sends out teams consisting of a crisis worker with substantial experience in mental health and a nurse, an emergency medical technician, or a paramedic to respond to 911 calls that are deemed nonviolent by trained local police dispatchers. The team responds without police officers, stabilizing the person and providing transportation or referrals for additional treatment. Police backup is called only when necessary.


In Los Angeles, a newly approved program-the Therapeutic Transportation Pilot Program-also dispatches unarmed crisis response teams in response to 911 calls involving nonviolent mental health and substance abuse crises, providing referrals to treatment resources and other support services. An initiative called Law Enforcement Assisted Diversion in Seattle allows people who are involved in minor drug offenses, prostitution, and crimes of poverty to avoid prosecution and jail. Instead, they are connected with crisis response professionals, substance use treatment resources, and social services, including housing assistance and mental health programs. In Dallas, the Rapid Integrated Group Healthcare Team program diverts patients with mental illness from EDs and jails by stabilizing them at the scene and referring them to appropriate social and health services.



"Police need a skill set to distinguish a person with symptoms of mental illness from someone who may commit a criminal act," says Jeannine Loucks, MSN, RN-BC, PMH, who has worked in psychiatric departments for more than four decades, most recently at St. Joseph Hospital in Orange, California. To help officers become better equipped to respond to 911 calls involving people with mental illness, Loucks created an educational program that began as an eight-hour training session but has been increased to 16 hours over two days. Implemented by police departments throughout California, the program offers an overview of mental illness-including major diagnoses-and helps police officers better interpret body language, improve communication skills, and deescalate a potentially contentious situation.


"There is still a lot of stigma surrounding mental health," Loucks says. That stigma, according to an article by da Silva and colleagues last year in Frontiers in Psychiatry, in part stems from the perception that people with mental illness are prone to violence. But although aggressive agitation is known to occur in those who have severe mental illness, research shows it's only significant in people who also have a substance abuse disorder or dependency.


"People with mental health issues are only violent when they feel attacked," says Loucks. "We need to engage with them correctly and treat them like human beings. They get stigmatized every day, even by health care workers. I teach my staff, 'You need to treat psychiatric people as patients who have had a full attack of the brain, just as you would treat a patient with a full attack of the heart.'"


A contributing factor to stigma, according to the Frontiers in Psychiatry article, is a lack of knowledge about mental illness. The primary source of information about mental illness for many people is mass media, including movies and social networks that tend to portray mental illness negatively, inaccurately, or both. "Since psychotic breaks, suicide, and aggravating situations can be shown in distorted or even comical ways," write the authors, "the severity of emergency situations involving mental illness may not be recognized."


Loucks agrees. "We need to start at the front end," she says. "Let's start with education at the police academy. Maybe then there would be better outcomes at the back end."



Reimagining the role of the police, while a worthy first step, is not enough, according to a November 2020 report by the Brookings Institution. Other actions to be considered include expanding access to behavioral health treatment, increasing investment in training for select volunteer police officers to respond to situations involving mental illness, measuring the results of crisis intervention strategies and programs, creating networks of crisis intervention training pilot programs that allow various jurisdictions to learn from one another and share best practices, developing projections of cross-departmental costs and benefits to encourage investment in programs, exploring alternate sources of funding, establishing dispatcher training for handling possible mental health calls, and securing the support of the federal government to build information networks and fund research.


"We don't do enough," says Loucks. "Psychiatric patients are underserved. Caseloads are unrealistic." And the pandemic, she adds, has only exacerbated the situation. "As a practitioner, I'm also concerned about how COVID is going to affect people with mental illness. There has been a big increase of first-time [psychotic] breaks, but these tend to be in people with anxiety and depression. There has also been a big rise among adolescents. We can do better. But we need more funding, more treatment, especially more long-term treatment. Unfortunately, nobody wants to pay."-Dalia Sofer