Guide No.40 (2006)

By Gary Cordner

The Problem of People with Mental Illness

Problems associated with people with mental illness pose a significant challenge for modern policing. [1] This guide begins by describing the problem and reviewing factors that increase the challenges that police face in relation to the mentally ill. It then identifies a series of questions that might help you analyze your local policing problems associated with people with mental illness. Finally, it reviews responses to the problems and what we know about these from evaluative research and police practice.

Police officers frequently encounter people with mental illness—approximately 5 percent of U.S. residents have a serious mental illness,§ and 10 to 15 percent of jailed people have severe mental illness. [2] An estimated 7 percent of police contacts in jurisdictions with 100,000 or more people involve the mentally ill.[3] A three-city study found that 92 percent of patrol officers had at least one encounter with a mentally ill person in crisis in the previous month,[4] and officers averaged six such encounters per month. The Lincoln (Nebraska) Police Department found that it handled over 1,500 mental health investigation cases in 2002, and that it spent more time on these cases than on injury traffic accidents, burglaries, or felony assaults. [5] The New York City Police Department responds to about 150,000 “emotionally disturbed persons” calls per year.[6]

It is important to recognize at the outset that mental illness is not, in and of itself, a police problem. Obviously, it is a medical and social services problem. However, a number of the problems caused by or associated with people with mental illness often do become police problems. These include crimes, suicides, disorder, and a variety of calls for service. Moreover, the traditional police response to people with mental illness has often been ineffective, and sometimes tragic.

Unfortunately there is not one standard definition of mental illness. Medical doctors, research scientists, psychiatrists, psychologists, and social workers define it differently depending on whether their focus is more on organic conditions, personality, or behavior. One working consensus definition designed for policy makers is “Mental illness is a biopsychosocial brain disorder characterized by dysfunctional thoughts, feelings, and/or behaviors that meet DSMIV diagnostic criteria” (Kelly, 2002). The same report identifies the main examples of serious mental illness as:

All cases of schizophrenia (a psychotic disorder)

Severe cases of major depression and bipolar disorder (mood disorders)

Severe cases of panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder (anxiety disorders)

Severe cases of attention deficit/ hyperactivity disorder (typically, a childhood disorder)

Severe cases of anorexia nervosa (an eating disorder).

Timothy A. Kelly (2002) “A Policymaker’s Guide to Mental Illness.” Washington, DC: The Heritage Foundation.

Over the last decade, many police agencies have sought to improve their response to incidents involving people with mental illness, especially emergency mental health situations. These new developments, however, have been targeted almost exclusively at improved handling of individual incidents. Little attention has been devoted to developing or implementing a comprehensive and preventive approach to the issue.

Common Situations

Police officers encounter people with mental illness in many different types of situations, in roles that include criminal offenders, disorderly persons, missing persons, complainants, victims, and persons in need of care (see table). According to one Texas study,[7] the five most frequent scenarios are as follows:

A family member, friend, or other concerned person calls the police for help during a psychiatric emergency.

A person with mental illness feels suicidal and calls the police as a cry for help.

Police officers encounter a person with mental illness behaving inappropriately in public.

Citizens call the police because they feel threatened by the unusual behavior or the mere presence of a person with mental illness.

A person with mental illness calls the police for help because of imagined threats.

Of these typical situations, ones involving the threat of suicide were rated as the most difficult to handle. Each of the others listed above was rated as somewhat difficult to handle. The two behaviors that were rated as most problematic overall were threatening suicide and nuisance behaviors.

Roles of People with Mental Illness and Examples

Role Examples

Offender

A person with mental illness commits a personal or property crime.

A person with mental illness commits a drug crime.

A person with mental illness threatens to commit suicide.

A person with mental illness threatens to injure someone else in the delusional belief that that person poses a threat to him or her.

A person with mental illness threatens to injure police as a means of forcing police to kill him (commonly called “suicide by cop”).

Disorderly person

A family or community member reports annoying or disruptive behavior by a person with mental illness.

A hospital, group home, or mental health facility calls for police assistance in controlling a person with mental illness.

A police officer on patrol encounters a person with mental illness behaving in a disorderly manner.

Missing person

A family member reports that a person with mental illness is missing.

A group home or mental health institution reports that a person with mental illness walked away and/or is missing.

Complainant

A person with mental illness calls the police to report real or imagined conditions or phenomena.

A person with mental illness calls the police to complain about care received from family members or caretakers.

Victim

A person with mental illness is the victim of a personal or property crime.

A family member, caretaker, or service provider neglects or abuses a person with mental illness.

Person in need of care

Police are asked to transport a person with mental illness to or from a hospital or mental health facility.

Police encounter a person with mental illness who is neglecting his or her own basic needs (food, clothing, shelter, medication, etc.).

These are the most common situations in which police encounter people with mental illness. It is important to realize, though, that when police officers handle some of these situations they do not always realize that mental illness is involved (such as a shoplifting or a disorderly person). Officers may try to handle the situation as usual (by giving directions, issuing commands, or making an arrest, for example) but not get the cooperation or compliance expected, sometimes leading to escalating tension. This highlights the importance of training in mental illness recognition as well as crisis management techniques.

Dangerousness

A fairly common perception is that people with mental illness are disproportionately involved in violent crime. This is true in one respect but not in another. A small subset of people with mental illness, those who are actively experiencing serious psychotic symptoms, are more violent than the general population. Research suggests several factors associated with this group’s violent behavior, including drug and alcohol abuse, noncompliance with medication requirements, and biological or biochemical disorders.[8] In general, however, “violent and criminal acts directly attributable to mental illness account for a very small proportion of all such acts in the United States. Most persons with mental illness are not criminals, and of those who are, most are not violent.” [9]

Police interactions with people with mental illness can be dangerous, but usually are not. In the United States, 982 of 58,066 police officers assaulted in 2002, and 15 of 636 police officers feloniously killed from 1993 to 2002, had “mentally deranged” assailants. [10] These represent one out of every 59 assaults on officers and one out of every 42 officers feloniously killed—relatively small portions of all officers assaulted and killed.

Encounters with police are more likely to be dangerous for people with mental illness than for the police. An early study found that an average of nine New York City police shootings per year between 1971 and 1975 involved emotionally disturbed people. [11] Between 1994 and 1999, Los Angeles officers shot 37 people during encounters with people with mental illness, killing 25. [12] A review of shootings by the police from 1998 to 2001 in the United Kingdom indicated that almost half (11 out of 24) involved someone with a known history of mental health problems. [13] It is estimated that people with severe mental illness are four times more likely to be killed by police. [14] Serious injury and death of people with mental illness at the hands of the police are especially tragic, for obvious reasons. Reduction of such injuries and deaths should be a high-priority objective for every police agency.

Harms

The harms associated with the police handling of people with mental illness are implicit in the situations and examples the table provides, but deserve some discussion. A person with mental illness may harm other citizens by committing personal or property crimes or engaging in disorderly and disruptive behavior. Alternatively, a person with mental illness may be harmed as a crime victim, as an abused family member or patient, as a person who suffers through self-neglect, or as a person whose mental health problem has left him or her erroneously subjected to criminal charges and jail confinement. Society in general may be harmed if excessive police, criminal justice, and/or medical resources are consumed by problems associated with people with mental illness.

It is important to keep the concept of harm in mind when addressing this particular problem, because there is a tendency to simply define people with mental illness as the problem, and getting them out of sight as the solution. In contrast to most police problems, however, this is not one that involves wholly voluntary behavior— rather, it involves behavior that medical conditions cause or compound. Consequently, police have to be careful not to blame people with mental illness, but instead focus on behavior that causes harm to self or others.

Related Problems

The police problem of people with mental illness is closely connected to three other problems noted below. This guide does not specifically address these problems, but addressing people with mental illness in your jurisdiction may require that you take on these problems, as well:

homelessness

drug abuse

alcohol abuse

The people the police encounter who have mental health problems or emergencies are also frequently homeless. For example, a Honolulu study found that 74 percent of law violators who the police believed to have a mental disorder were also homeless.[15] In London, about 30 percent of minor offenders referred for admission to a station-house diversion program for the “mentally disordered” were living on the streets. [16]

Similarly, the people with mental illness the police encounter are likely to have substance abuse problems. About three-quarters of jail and prison inmates with mental illness also have a substance abuse problem. [17] Current substance abuse was identified for about half of psychiatric emergency room referrals in New York State, [18] and nearly two-thirds of psychiatric emergency patients evaluated by a police-mental health outreach team in Los Angeles were known to be serious substance abusers.[19]

Factors Contributing to the Problem

Understanding the factors that contribute to your problem will help you frame your own local analysis questions, determine good effectiveness measures, recognize key intervention points, and select appropriate responses. Four important factors that strongly affect the current mental health situation in America are deinstitutionalization, criminalization, medicalization, and privatization.

Deinstitutionalization

Perhaps the single biggest factor affecting the policing of people with mental illness has been deinstitutionalization. [20] During the 20th century, and especially after 1960, public attitudes, laws, and professional mental health practices changed, leading to the closing of many state hospitals, psychiatric hospitals, and what used to be called insane asylums. Society’s preference shifted away from institutionalizing people with mental illness. Unfortunately, adequate community-based services to pick up the slack were never provided. This vacuum persists to this day, to the extent of complete failure of the mental health system in many jurisdictions.

Criminalization

After deinstitutionalization, many people with serious mental illnesses were returned to the community, but adequate community-based services were not established. Predictably, calls to the police about crimes and disorder involving people with mental illness increased. [21] Police tried to handle many of these calls informally, but if the behavior persisted, options were limited. Frequently, efforts at civil commitment were unsuccessful (the person had to pose a danger to him-or herself or others), and other inpatient or outpatient mental health services were unavailable, cumbersome, or uncooperative. Inevitably, police often turned to arrest and a trip to jail as the only available solution to the immediate problem. This had the general effect of criminalizing mental illness and reinstitutionalizing people with mental illness—but in jail or prison instead of a psychiatric facility. One analysis concluded that “in 1955, [0].3 percent of the U.S. population was mentally ill and residing in a mental institution; whereas in 1999, [0].3 percent of the national population is mentally ill and is in the criminal justice system.” [22]

Medicalization

The dominant treatment for mental illness has evolved from electric shock and psychotherapy more toward medication. To be sure, other treatments remain viable, and combined treatments are generally preferred, but today, medication plays a central role. Consequently, an important aspect of community-based mental health care is getting noninstitutionalized people with mental illness to take their medication as prescribed. [23] Factors that interfere with regular use of prescribed medications include the negative side effects associated with some drugs, the high cost of medication, the tendency to self-medicate, the abuse of illegal drugs and alcohol, and the lack of monitoring/follow-up by the overtaxed community-based mental health system.

Privatization

Many of today’s community-based mental health facilities, especially group homes, are operated by private individuals or companies. To be sure, government-run mental health facilities can be inefficient, callous, and neglectful. However, private profit-making facilities introduce another issue—greed. Privately run facilities have an inherent incentive to cut expenses; this often translates into minimum staffing levels and low-paid staff, which in turn results in a facility that relies on the police to help manage patients/clients. As a result, police resources are wasted and people with mental illness do not get the quality of care that they deserve.

Understanding Your Local Problem

The information provided above is only a generalized description of police problems associated with people with mental illness. You must combine the basic facts with a more specific understanding of your local problem. Analyzing the local problem carefully will help you design a more effective response strategy.

Asking the Right Questions

The following are some critical questions you should ask in analyzing your particular problem of people with mental illness, even if the answers are not always readily available. Your answers to these and other questions will help you choose the most appropriate set of responses later.

Incidents

It is important to gather information about the quantity and types of incidents involving people with mental illness. A jurisdiction may find that one or two particular types of incidents constitute a large part of its problem, providing a focus for analysis and response. This information may be difficult to obtain, however, because many police agencies’ call classification systems do not include a code for “person with mental illness,” “mental health emergency,” or “emotionally disturbed person.”

If the police department’s communications system does not provide reliable data, it may be necessary to do a special study in which officers and dispatchers record this type of information for some months to facilitate problem analysis. Another option is to backtrack from known indicators of incidents involving people with mental illness. For example, if one call at an address is found to involve a victim with mental illness or a false complaint reported by someone with mental illness, all previous calls at that address could be analyzed to check for a hidden hot spot. Similarly, all previous calls involving the particular person (victim or complainant) could be extracted from the department’s computer system to determine if the individual might be an unrecognized repeat victim or repeat false complainant.

You should not overlook other data sources. Hospitals (general and/or psychiatric), ambulance services, and community-based mental health agencies might have useful data on commitments, referrals, and transports. In addition, academic institutions and mental health advocates might have conducted studies of the mental health situation in your jurisdiction, or they might be willing to partner with the police agency in conducting such studies.

How many total incidents involving people with mental illness does your agency handle in a year, and how much police time is consumed?

How many of each type of incident involving people with mental illness does the agency handle in a year, and how much police time does each consume?

How do police handle incidents (informal handling, formal referral, involuntary commitment, arrest, etc.) for each type of incident involving people with mental illness?

How often do officers use force when handling incidents involving people with mental illness?

How often are officers injured when handling incidents involving people with mental illness?

What proportion of people with mental illness whom officers encounter are homeless and/or serious substance abusers?

Stakeholders

It is important to identify institutions, organizations, and individuals in the community who play significant official or unofficial roles in the mental health system. Since most police officers are not intimately familiar with all the players in the mental health system, these stakeholders and potential guardians may not be well known or obvious. Because these entities can contribute expertise, authority, and resources, though, it is very beneficial to identify them and, if possible, engage them as participants in collaborative problem-solving.

What public and private inpatient and outpatient psychiatric/mental health facilities (psychiatric hospitals and wards) are located in or serve the jurisdiction?

What other residential facilities serving people with mental illness (group homes, assisted living facilities, nursing homes, etc.) are located in or serve the jurisdiction?

What other services for persons with mental illness are provided in the jurisdiction through the public health department, general hospitals, counselors, therapists, etc.?

What laws and regulations govern the mental health system’s operation in your jurisdiction?

What advocacy organizations representing people with mental illness, such as the National Alliance for the Mentally Ill or the Mental Health Association, are in the jurisdiction?

What types of mental health services does the local jail provide?

What institutions and organizations provide services in the jurisdiction for people who are homeless or who have serious substance abuse problems?

In regard to each of the items above, how does the system differ for minors (juveniles)?

Victims

Identifying victims is important because certain categories of people, or even some specific individuals, may be more heavily victimized than others, suggesting avenues for problem-solving activity. Victims in situations involving people with mental illness might include specific community members, mental health workers, family members, or the mentally ill themselves. When any of these people become crime victims, the police may be notified, although of course many crimes also go unreported. Unfortunately, even when reported, such crimes may not be flagged or marked as involving a person with mental illness. This can make it difficult to identify both one-time and repeat victims.

When people with mental illness commit a crime, who are the victims (strangers, businesses, caregivers, etc.)? Who are repeat victims?

When people with mental illness cause nuisances and disorder, who are the victims? Who are repeat victims?

When crimes are committed against people with mental illness, who are the victims and what are their circumstances (family members, institutional residents, etc.)? Who are repeat victims?

When people with mental illness are neglected and/or abused, who are they and what are their circumstances? Who are repeat victims of neglect and abuse?

Offenders

It is important to look for people who cause a disproportionate share of the problem. People with mental illness may be offenders, or others may commit offenses against them. As mentioned above, however, it can be difficult to identify cases involving people with mental illness from police data, thus making it challenging to identify offenders and repeat offenders associated with such cases.

Which people with mental illness commit personal and property crimes? Who are the repeat offenders?

Which people with mental illness cause nuisances and disorder? Who are the repeat offenders?

What crimes do people commit against people with mental illness? Who are the offenders? Who are the repeat offenders?

Who neglects and/or abuses people with mental illness? Who are the repeat offenders?

Related:

Mentally ill languish in jails due to cuts, lack of beds

By Jocelyn Wiener, CHCF Center for Health Reporting

This story was originally published in The Modesto Bee.

(Lauren M. Whaley/CHCF Center for Health Reporting)

The latest chapter of Kim Green’s recurring nightmare began last fall.

In October, her 24-year-old daughter – who suffers from severe bipolar disorder and a mood disorder related to schizophrenia – was booked into the county jail after being arrested on a probation violation. In December a judge declared the young woman incompetent to face charges and ordered her to Napa State Hospital to get well.

But with no beds available at Napa, Green said, her daughter instead spent five months in the jail.

Deputy David Frost, who oversees the jail’s two mental health wings, said it’s not uncommon for seriously ill inmates to wait there for months, even after a judge orders them transferred to a state hospital.

“The misconception is that mentally ill offenders are just these raging (people), punching walls. They’re not. They’re pretty much scared people,” Deputy Frost said.

In recent years, Stanislaus County – like counties around California – has been severely impacted by budget cuts to mental health services. As those services have disappeared, the number of people with mental illness landing behind bars has surged. In the past six years, the numbers of mentally ill inmates in the Stanislaus County jail increased nearly 50 percent, according to sheriff’s department data.

Around the state, many of the most seriously mentally ill inmates are now waiting three to six months in jail before a state hospital bed opens up, said Randall Hagar, director of government affairs for the California Psychiatric Association. He calls the situation, which he says has gotten worse in recent years, “tragic.”

 

“It’s terrible, because they’re just sitting there and they’re not getting any help,” said Shannon McBride, the deputy public defender representing Green’s daughter. “The environment is such that for a lot of them, they just get worse during that time.”

Green, a registered nurse, says her daughter has been sick since she was a little girl – at the age of four, she tearfully told Green that she didn’t want to be alive anymore. By six, she was hearing voices. Now her family watched, helpless, as she waited in jail, off her medication and increasingly lost in her delusions.

“I guarantee that with no help, she will end up dead or in the system,” Green said.

Advocates emphasize that state hospitals are not ideal places for the majority of seriously mentally ill patients — many of who might flourish if they received intensive support services in the community. But few suggest the jails are a better substitute.

“The criminalization of the mentally ill is Exhibit A for how, as a society, we have not made mental health a priority,” said Darrell Steinberg, state senate president pro tempore. Steinberg said this criminalization was one of the main reasons he authored the Mental Health Services Act, a 2004 ballot measure that levied a one percent tax on millionaires to fund innovative programs for the state’s mentally ill.

Stanislaus County has created several innovative programs out of that and other funding sources in recent years, including a few that specifically target the intersection of law enforcement and the mentally ill.

Innovations have included the creation of a special court to handle mental health cases, and a mobile community emergency response team that pairs mental health technicians and psychiatric nurses with officers responding to mental health crisis calls. The county also created intensive, coordinated support services for small groups of individuals with mental illnesses, including criminal offenders.

But these recent innovations have faced competition as core mental health services have been stripped away by budget cuts. And some programs – including the mental health court and the community emergency response teams — have faced cutbacks due to budget constraints in the past several years.

“It’s hard when you see how effective you can be with your small group of people, but you know there’s probably 100 mentally ill in jail right now that would benefit …but we’re at capacity all the time,” said Debra Buckles, chief of forensic services for Stanislaus County Behavioral Health and Recovery Services.

Kim Green and her older daughter, Stephanie Hatfield, think about the shortage of services all the time.

One rainy day this March, Hatfield leaned forward in her seat in the downtown Modesto courtroom, straining to hear news of her little sister. For up to 23 hours a day over the past several months, jail deputies had locked her sister inside a 6-foot-by-9-foot cell, furnished with a thin metal bunk, a small wood desk, a sink and a toilet, in the special wing that houses the sickest of the mentally ill – the 24-cell B-Mental Health Unit.

Today, the young woman was supposed to appear before a judge.

“I hope that’s her with the chains on,” Hatfield said, as she heard a metallic clinking coming from an adjacent room. “I just want to see her.”

A thin bearded man in a white and orange striped jumpsuit walked out instead.

Eventually, Hatfield was able to glean that her sister had been transferred to Napa State Hospital the day before – after five months in jail. Hatfield was relieved that her sister was not back out on the streets. At least not yet.

Her mother, Green, a registered nurse, describes her youngest daughter as a “sweet, loving, charismatic, artistic” person when she’s on her medication, though she’s “never been really okay, completely.” Starting when she was small, she was deemed sick enough to receive intensive mental health services from Stanislaus County, Green said. Her daughter received excellent services from the county until she was 18, she said, including placement in high-level group homes that provided psychiatry and medication and follow-up.

But after the young woman legally became an adult, her mother said, those services largely dropped away. Her daughter fled a group-living environment where she felt threatened by other occupants. She ended up cycling between the streets, family members’ homes, and single-room occupancy hotel rooms that crawled with roaches and had no locks on the doors. On one occasion, a pimp held the young woman against her will, her mother said.

At some point, society began to classify her as a criminal.

In 2008, the young woman spat on a jail deputy while being restrained and was charged with assaulting an officer, said McBride, her public defender. Ever since, probation violations on that one case have caused her to cycle in and out of jail and state mental hospitals, her mother said. Each time, once she stabilizes, a judge releases her to the streets with minimal follow-up by the mental health system, she said.

“It’s not that we’re denying that our loved one has a problem. But if there is no help available, people end up paying the cost,” Green said. “If they don’t have a program, a plan, a place that puts them in another direction, it’s guaranteed to fail.”

Joyce Plis, executive director of the Stanislaus County chapter of the National Alliance for the Mentally Ill, said families often seek help before their loved ones get in trouble with the law. But it can be “almost impossible” to find them services, she said, especially for those who don’t recognize how sick they are.

Instead, some individuals with mental illness end up committing crimes – petty theft, drug use, threatening or assaulting a friend or family member– and then landing in jail. Only there do they finally get some basic care, she said.

She describes life behind bars as “horrendously awful” for someone trying to get well, with inmates who are off their medications hallucinating and yelling. Treating individuals in jail and hospitals because they can’t get services beforehand also ends up being extremely expensive for the public, Plis said.

“People with mental illness don’t serve their time and get out,” she said. “They get stuck in there.”

Madelyn Schlaepfer, director of Stanislaus Behavioral and Recovery Services, said the county is working to find ways to keep sick people from cycling back into psychiatric hospitals and jails. The challenge, she says, is the scarcity of resources.

“It is really a struggle to find aftercare,” Schlaepfer said.

Law enforcement officials say those problems are being amplified by public safety realignment. Starting last fall, state prisons have been granting early release to increasing numbers of nonviolent offenders, adding additional pressures to county probation departments and jails. Stanislaus County expects to absorb 500 to 600 inmates every year. Many of them, said Sheriff Adam Christianson, have mental illnesses. Frequently, they land back in jail.

The jail system had a bed capacity problem before realignment, Christianson said. “Now that problem has been exacerbated exponentially.”

Dr. Antoun Manganas, medical director of Doctors Behavioral Health Center in Modesto, said the psychiatric crisis center has begun seeing very ill inmates appear at their doors on the day they are released from prison.

“All of a sudden they show up and they say, ‘I don’t have my medication, I don’t have money, and I don’t have a home,’” he said. “And they are in a crisis.”

Kim Green and her older daughter, Stephanie Hatfield, were hoping that wouldn’t be the outcome for Hatfield’s baby sister.

On her sister’s 24th birthday in March, Hatfield, her brother and sister-in-law visited the young woman at Napa State Hospital. Sitting at the visitors’ table, Hatfield thought her sister looked very pale and skinny. After spending so many months locked inside without medication, she said her sister was the sickest she’d ever seen her.

Hatfield’s sister told her that she was being taught about court in the state hospital. “The judge is there,” Hatfield recalled her sister saying. “So is the public defender. And the lady who takes notes on the typewriter. And the demons.”

This past Thursday morning, Hatfield rushed, once again, to the courthouse in downtown Modesto. After two months in the state mental hospital, her sister had just been transferred back to the jail, and was likely to be declared well enough to face her charges.

“I’m scared to death,” Hatfield said. “They’re just going to let her out. She’s not going to get the help she needs. And she’s going to be back on the streets.”

The bailiff called the courtroom to order. The judge entered. The public defenders and district attorneys took their seats.

And then Hatfield’s little sister appeared, her straight brown hair pulled into a ponytail, a grin stretched across her beaming young face.

She turned around to search for Hatfield, then smiled and waved.

“I’m going home,” she whispered.

A few minutes later, the judge read the charges aloud.

“No contest, sir,” the young woman said.

Time served, said the judge.

Hatfield’s eyes filled with tears, as she made plans to pick up her sister later that day.

“Now we start over again,” she said.

END
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