The Problem of People with Mental Illness
Problems associated with people with mental illness pose a significant challenge for modern policing.  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.  An estimated 7 percent of police contacts in jurisdictions with 100,000 or more people involve the mentally ill. 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, 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.  The New York City Police Department responds to about 150,000 "emotionally disturbed persons" calls per year.
§ 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.
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.
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.
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, 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|
|Person in need of care|
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.
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. 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." 
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.  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.  Between 1994 and 1999, Los Angeles officers shot 37 people during encounters with people with mental illness, killing 25.  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.  It is estimated that people with severe mental illness are four times more likely to be killed by police.  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.
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.
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:
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. 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. 
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.  Current substance abuse was identified for about half of psychiatric emergency room referrals in New York State,  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.
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.
Perhaps the single biggest factor affecting the policing of people with mental illness has been deinstitutionalization.  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.
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.  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, .3 percent of the U.S. population was mentally ill and residing in a mental institution; whereas in 1999, .3 percent of the national population is mentally ill and is in the criminal justice system." 
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.  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.
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.
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