New guidance for law enforcement personnel from the FBI/ Responding to Persons with Mental Illness


Responding to Persons with Mental Illness

By Abigail S. Tucker, Psy.D., Vincent B. Van Hasselt, Ph.D., Gregory M.
Vecchi, Ph.D., and Samuel L. Browning, M.S.

FBI Law Enforcement Bulletin   October 2011

While police officers may not consider providing services to persons
with mental illness one of their primary functions, they respond to
challenges and dangers that ordinary citizens and social service
agencies are not equipped to manage. In addition to their roles as
investigators and protectors, police still must keep the peace.1
However, a review of case records illustrates the frustrating and often
tragic outcome of police calls for assistance pertaining to mental
illness. A closer look at these instances demonstrates that officers
usually serve as an initial contact for both the criminal justice and
the social service systems. Unfortunately, a disconnect exists in the
process from the first police response to the next level of appropriate
care due largely to a lack of proper training, resources, and
collaborative community support.2

Historical Perspectives

The trend toward deinstitutionalization between the 1960s and 1980s
contributed to the increased contact between police and individuals with
mental illness.3 Further, the curtailment of federal mental health
funding and the introduction of legal reforms have given these persons
the right to live in the community without treatment.4 However, many of
the legal reforms in the 1970s affected people with mental illness by
instituting laws for involuntary treatment, as well as those for
nondangerous offenses (e.g., responding verbally to auditory
hallucinations in public parks, sleeping on park benches). Beginning in
the 1950s, officers adhered to the professional model, which used
experts from other fields (e.g., psychologists, advocacy lawyers) to
bolster police reform and response to mental illness.5 Such goals, while
highly commendable, often were not realized by police agencies due to
financial constraints, a lack of realistic application, and the
inability of the consulting professionals to offer useful guidelines.

Upon confrontation with individuals with mental illness, police have
three main options: 1) transport them to a receiving psychiatric
facility; 2) use informal verbal skills to de-escalate the situation; or
3) arrest the individual.6 These possible actions stem from basic
concepts that guide police in all citizen encounters-the duty of the
officer to protect and serve the community and the governing reforms
that stipulate the power of an officer to involuntarily protect those
behaving irrationally who may harm themselves or others.7

Recently, more comprehensive and flexible approaches have arisen;
however, they are in the minority. Examples include specialized police
training and units, community-collaborative programs, and crisis
intervention training. As widespread media coverage in the past decade
has underscored, these limited options can lead to cases resulting in
death or injury. Even more tragic is the increase in police-assisted
suicide, defined by Police Officer Standards and Training as "an
incident in which an individual engages in behavior which poses an
apparent risk of serious injury or death, with the intent to precipitate
the use of deadly force by law enforcement personnel toward that
individual." Research shows that a significant number of persons
committing this act have some form of mental illness.8

Specialized Police Response Models

Officers often receive blame for lethal outcomes in situations involving
mental illness. Four decades ago, police were described as often being
pigeonholed into making medical decisions with little training and few,
if any, response options.9 Ironically, this conclusion still proves
largely relevant today.

As one possibility, law enforcement agencies can employ police-referral
programs. An examination of a police-referral program that designated an
intake unit at a community mental health center (CMHC) found that
streamlining the process of how officers refer individuals with mental
illness to hospitals bolstered the program's effectiveness.10
Additionally, the analysis showed that a collaborative response between
police and the CMHC reduced recidivism rates in referred psychiatric
patients.

Police also can incorporate specialized programs. One report noted that
although more than 50 percent of departments nationwide do not have such
a program/response, most rate themselves as effective in managing
service calls pertaining to mental illness.11 This contradicts research
that points to the efficacy of specialized response programs.12 In an
encouraging trend, more recent efforts suggest that the number of law
enforcement agencies reporting specialized training and units for
dealing with persons with mental illness is increasing.13

Crisis Intervention Teams
The Memphis Model of Crisis Intervention Team (CIT) provides a framework
for a police-based specialized officer response now well established in
the field. CIT was created in Memphis, Tennessee, in 1988 following the
tragic death of a suicidal man with schizophrenia.14 Although many
officers of the Memphis Police Department knew of his mental illness,
the ones responding to the particular incident were unfamiliar with him.
When police confronted him and demanded that he drop his knife, the
young man became upset and made a sudden move toward the officers,
forcing them to shoot (as they had been trained to do in such
situations) and fatally wound him. Following this incident, the
community demanded a response.

Unfortunately, this does not represent an isolated incident; law
enforcement interactions with persons with a mental illness more
frequently result in the use of force by police than incidents involving
individuals who do not suffer from a mental condition.15 This can lead
to injury of both the individuals and the officers. However, some of the
incidents that result in the death of citizens at the hand of law
enforcement personnel cannot be avoided, as in the case of individuals
who commit suicide by cop. CIT offers investigators insight into these
persons and, perhaps, options to pursue during their exchanges with
them. The CIT model incorporates two main components: 1) a collaborative
framework between the community mental health resources, recipients of
those services, and local law enforcement agencies; and 2) specialized
training for CIT officers in mental health issues, crisis intervention,
and de-escalation.16

Collaborative Framework
Collaborations between policy makers, law enforcement, the regional
division of the National Alliance for the Mentally Ill (NAMI), persons
with a mental health issue, and others from the community began to form
in the initial CIT planning stages. One example of these collaborations
in Memphis was the formation of a single-location mental health care
facility for police drop-offs, called the Med.17 This facility enacted
for police a no-refusal policy for officer referrals and streamlined the
intake process to allow them to admit someone with mental illness and
get back on patrol within about 30 minutes.

Officer Training
In addition to collaborations and policy changes, certain officers are
selected or volunteer to receive specialized training as part of the
40-hour CIT training program. The CIT curriculum includes recognition
and understanding of the signs/symptoms of mental illnesses (e.g.,
schizophrenia, depression, personality disorders); pharmacological
interventions and their side effects; crisis intervention and
de-escalation skills; and knowledge of the user-friendly mental health
resources available to individuals. In addition, role playing gives
officers opportunities to practice crisis situations involving persons
with mental illness. Feedback and reinforcement are provided concerning
the officers' verbal and nonverbal behaviors in these scenarios.

Mental health professionals from the community teach the majority of the
course components; patients and their families also participate in
educating the officers on relevant mental health challenges and issues
to add perspective. Police learn how to recognize severe mental illness
and how these different disorders affect the individuals. At the end of
the course, officers graduate with CIT certification and receive a pin
to wear on their uniforms, identifying them as CIT officers. This allows
persons with mental illness in crisis to recognize CIT officers and also
serves as a source of pride for the law enforcement professionals.

Research Support
Experts evaluated the Memphis CIT model by comparing perceived
preparedness, quality of response to persons with mental illness,
diversion from jail, officer time spent on these calls, and community
safety and found empirical support for the effectiveness of this
approach.18 Additional researchers expanded on this work by using arrest
rates and feedback from referral sources.19 Their results provided
further support for the Memphis CIT model with findings of higher
response rates and fewer arrests. Also, it appears that an integral
component of CIT training is the use of crisis intervention and active
listening skills (e.g., paraphrasing, reflecting emotions, asking
open-ended questions), which are critical for de-escalating crisis
situations in general and situations involving individuals with mental
illness in particular.20 Apparently, psychological evaluation concerning
mental health issues, as well as crisis intervention skills training,
both comprise important aspects of CIT.

Barriers and Concerns
One barrier in the development of police-based specialized officer
response is the definition of training in the field of law enforcement.
Basic officer training will prove inadequate in addressing this growing
and volatile problem without ongoing review and skill maintenance.
Researchers note the common misperception that all police officers have
the same mandated training and available resources.21 Other experts
contend that for specialized response programs to work effectively,
training is a crucial element. Law enforcement training is most
effective when it includes consultation with mental health professionals
and other administrative and social service systems.22

The mental health care system itself appears to be another barrier to
policing progress involving mental health situations. Social service
agencies often refuse to admit intoxicated or psychotic persons referred
by police. In addition, the "revolving door" phenomenon of recidivism
supports the reality of overworked and underpaid staff in receiving
facilities, such as hospitals and community mental health centers.
Specifically, many treatment facilities require police custody in the
waiting area for individuals transported for a mental disturbance. Also,
no systematic and hierarchical structure exists that links first
responders (e.g., police, EMS) with the appropriate level of care in the
mental health system (e.g., medical versus psychiatric hospitals, social
service shelters versus drug rehabilitation centers).

Findings
Overall, research supports the use of a specialized law enforcement
response to address the needs of persons with mental illness. In
particular, the Memphis CIT model is functional, generally accepted by
police departments, and, most important, effective.23

The utility of such programs is enhanced by the use of collaborative
drop-off sites. These allow for greater flexibility, provide ease and
speed in application, and serve as a more economical option. However, a
few important guidelines can make a substantial difference in
effectiveness. For example, researchers recommended police-friendly
procedures that include a no-refusal policy, an intake process with
streamlined paperwork, and consistent procedural steps.24

Conclusion
Police officers maintain and enforce public order. Their role as both
first responders and peacekeepers remains a challenge in many ways. The
law enforcement response to mental disturbance calls with ethical,
practical, and effective strategies requires interagency collaboration.
Numerous examples attest to the efficacy of police-based interventions
and collaborative policies and procedures. In particular, current
research supports the use of a specialized law enforcement response to
meet the needs and demands of persons with mental illness while ensuring
their safety and dignity.

Endnotes
1 G.W. Cordner, "A Community Policing Approach to Persons with Mental
Illness," Journal of the American Academy of Psychiatry and the Law 28
(2000): 326-331.
2 A.S. Tucker, V.B. Van Hasselt, and S.A. Russell, "Law Enforcement
Response to the Mentally Ill: An Evaluative Review," Brief Treatment and
Crisis Intervention 8 (2008): 236-250.
3 M. Zdanowicz, "A Sheriff's Role in Arresting the Mental Illness
Crisis," Sheriff 53 (2001): 2-4.
4 L.A. Teplin, "Keeping the Peace: Police Discretion and Mentally Ill
Persons," National Institute of Justice Journal 244 (2000): 8-15.
5 Cordner.
6 Teplin.
7 Ibid.
8 H.R. Hutson, D. Anglin, J. Yarbrough, K. Hardaway, M. Russell, J.
Strote,
M. Canter, and B. Blum, "Suicide by Cop," Annals of Emergency Medicine
32 (1998): 665-669; V.B. Lord, "Law Enforcement-Assisted Suicide,"
Criminal Justice and Behavior 27 (2000): 401-419; and A.J Pinizotto, E.F
Davis, and C.E. Miller, "Suicide by Cop: Defining a Devastating
Dilemma," FBI Law Enforcement Bulletin, February 2005, 8-20.
9 A.R. Matthews, Jr., "Observations on Police Policy and Procedures for
Emergency Detention of the Mentally Ill," The Journal of Criminal Law,
Criminology and Police Science 61 (1970): 283-295.
10 L.A. Teplin and E.P. Sheridan, "Police-Referred Psychiatric
Emergencies: Advantages of Community Treatment," Journal of Community
Psychology 9
(1981): 140-147.
11 M.W. Deane, H.J. Steadman,
R. Borum, B.M. Veysey, and J.P. Morrisey, "Emerging Partnerships Between
Mental Health and Law Enforcement," Psychiatric Services 50 (1999):
99-101.
12 Teplin and Sheridan; R. Borum, M.W. Deane, H.J. Steadman, and J.
Morrissey, "Police Perspectives on Responding to Mentally Ill People in
Crisis: Perceptions of Program Effectiveness," Behavioral Sciences and
the Law 16 (1998): 393-405; T.M. Green, "Police as Frontline Mental
Health Workers: The Decision to Arrest or Refer to Mental Health
Agencies," International Journal of Law and Psychiatry 20 (1997):
469-486; and H.J. Steadman, M.W. Deane, R. Borum, and J.P. Morrissey,
"Comparing Outcomes of Major Models of Police Responses to Mental Health
Emergencies," Psychiatric Services 51 (2000): 645-649.
13 J. Hails and R. Borum, "Police Training and Specialized Approaches to
Respond to People with Mental Illness," Crime and Delinquency 49 (2003):
52-62.
14 B. Vickers, U.S. Department of Justice, Bureau of Justice Assistance,
"Memphis, Tennessee, Police Department's Crisis Intervention Team,"
Bulletin from the Field: Practitioner Perspectives,
http://www.ncjrs.gov/pdffiles1/bja/182501.pdf (accessed August 20,
2010).
15 R.S. Engel and E. Silver, "Policing Mentally Disordered Suspects: A
Reexamination of the Criminalization Hypothesis," Criminology 39 (2001):
225-253.
16 R. Dupont and S. Cochran, "Police Response to Mental Health
Emergencies: Barriers to Change,"Journal of American Academy of
Psychiatry and the Law 28 (2000): 338-344; and Vickers.
17 Vickers.
18 Borum, Deane, Steadman, Morrissey, "Police Perspectives on Responding
to Mentally Ill People in Crisis."
19 Steadman, Deane, Borum, and Morrissey, "Comparing Outcomes of Major
Models of Police Responses to Mental Health Emergencies."
20 G.M. Vecchi, V.B. Van Hasselt, and S.J. Romano, "Crisis (Hostage)
Negotiation: Current Strategies and Issues in High Risk Conflict
Resolution," Aggression and Violent Behavior: A Review Journal 10
(2005): 533-551.
21 DuPont and Cochran.
22 H.J. Steadman, K.A. Stainbrook, P. Griffin, J. Draine, R. DuPont, and

C. Horey, "A Specialized Crisis Response Site as a Core Element of
Police-Based Diversion Programs,"Psychiatric Services 52 (2001):
219-222.
23 Dupont and Cochran.
24 Steadman, Stainbrook, Griffin, Draine, DuPont, and Horey.

http://www.fbi.gov/stats-services/publications/law-enforcement-bulletin/
october-2011/responding-to-persons-with-mental-illness

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