POP Center Problems People with Mental Illness, 2nd Ed. Page 3

Responses to People with Mental Illness

Your analysis of your local problem should give you a better understanding of the factors contributing to it. Once you have analyzed your local problem and established a baseline for measuring effectiveness, you should consider possible responses to address the problem. 

The following response strategies provide a foundation of ideas for addressing your particular problem. These strategies are drawn from a variety of research studies and police reports. Several of these strategies may apply to your community’s problem. It is critical that you tailor responses to local circumstances, and that you can justify each response based on reliable analysis. In most cases, an effective strategy will involve implementing several different responses. Law enforcement responses alone are seldom effective in reducing or solving the problem. Do not limit yourself to considering what police can do: consider who else in your community shares responsibility for the problem and can help police better respond to it. 

General Considerations for an Effective Response Strategy 

Police are first responders to people in mental health crisis; they are not treatment providers. Accordingly, their effectiveness must be measured against the following realistic objectives: 

• preventing physical harm occurring to or by mentally ill persons
• enforcing criminal laws when appropriate
• referring mentally ill persons, where appropriate and either voluntarily or involuntarily, to professional mental health care and treatment 

This said, the more that professional mental health care and treatment is available to people who need it, and the more effective that care and treatment is in alleviating mental illness, the less likely it will be that people will experience mental-health crises that precipitate police intervention in the first instance. Put another way, police effectiveness is significantly limited by the availability and effectiveness of professional mental-health services within any community.[34] The easier it is for people with mental illness—and the police assisting them—to access appropriate and affordable mental health services, the less likely it will be that people will experience the sort of mental crises that lead to emergency police intervention. 

Although it is generally assumed that it is desirable to divert mentally ill persons who commit some sort of law violation away from the criminal justice system and into the mental health system—whether prior to or after arrest—the existing research evidence is not yet conclusive as to the full effects of doing so.[35] Ideally, police interventions with mentally ill persons would result in less harm being caused by or to the person, improved mental health, and lower financial costs to society[36], but exactly how to achieve these and other desired outcomes is not yet fully known.[37] In the absence of conclusive evidence, it nonetheless seems reasonable for police to prefer diversion to the mental health care system unless special circumstances clearly call for a criminal law response. 

Both within the United States and in other countries there are a variety of models for how police respond to incidents involving people with mental illness. Although the quantity of evaluative research is growing, it does not, at present, appear to be conclusive as to which models work best, and why. Given the complexity of mental illness and the many ways in which it can affect police incidents, this is not surprising. However, it does appear safe to conclude that, to the extent police and mental health professionals collaborate and to the extent that police officers understand mental illness better and have ready access to assistance from mental health professionals, the more likely better results, across a range of outcomes, will be realized. 

1. Developing an integrated response model. To reduce the overall likelihood of police interventions with mentally ill people, proper diagnosis and treatment of mental illness should occur at all opportunities prior and subsequent to police intervention.† The so-called Sequential Intercept Model calls for effective recognition and treatment of mental illness, and diversion from the criminal process before even a first police intervention, but certainly after it occurs. This entails enhancing the capacity of communications call-takers, prosecutors, courts, and probation/parole agencies to both recognize signs of mental illness and, when appropriate, bring mental health services to bear for the individual.[38] 

† See National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit for further information (Substance Abuse and Mental Health Administration, 2020).

Because mental disorders often coincide with other social and behavioral problems, ideally, police officers would also be able to refer or transport people in crisis, as appropriate, to other types of emergency services, such as community mental health clinics, drug and alcohol detoxification or sobering centers, respite centers, suicide prevention hotlines, and homeless services facilities.[39] Dayton, Ohio, police formed a partnership with multiple social service agencies to reach out to mentally ill persons who had police contacts to identify their personal needs and work to address them.[40] Park Ridge, Illinois police joined in a community-wide response to addressing mental health.[41] Philadelphia police collaborated with its city department of behavioral health, business improvement district, and others to develop and test a new, more holistic approach to managing people who chronically came into contact with police on matters relating to their mental illness.[42] 

2. Working with the mental health community. Mental health professionals and others who work with or as advocates for people with mental illness can be viable partners with the police. They can provide training and direct assistance during emergencies. They provide inpatient and outpatient services for people with mental illness and operate emergency facilities. There seems to be a general recognition that “neither the mental health system nor the law enforcement system can manage mental health crises in the community effectively without help from the other.”[43] 

Working together can be a challenge, however. The police responsibility to reduce disorder and hold offenders to account does not always square with the clinical and treatment goals of mental health providers. For these reasons as well as privacy and confidentiality considerations, the law enforcement and mental health systems sometimes fail to share information fully or quickly.† When information sharing does occur, technological difficulties can arise due to differing computer systems and software. Also, each system tends to want to unload problematic individuals onto the other system.[44] Police often complain about the difficulty of getting hospitals to accept responsibility for people in crisis, while mental health professionals often complain that the police are too quick to seek civil commitment and too prone to place criminal charges.

The policing problems associated with people with mental illness provide an opportunity for collaboration and partnerships.[45] A number of agencies and individuals, besides the police, have a professional interest in, and responsibility for, preventing incidents and tragedies as well as improving immediate and follow-up services. Others, including people with mental illness and their families, have a more personal but no less compelling interest in the same ends. Police departments should take the lead, if necessary, in building collaboration and partnerships among these groups to enhance incident response, coordination, and prevention. Effective police-mental health collaborations require, at a minimum, communication at both the chief executive level and, perhaps most critically, closer to the line level where designated liaisons work out routine inter- and intra-agency problems.‡ 

‡ See the Council of State Governments Justice Center’s website (at /csgjusticecenter.org/projects/law-enforcement-mental-health-learning-sites/) that provides online information from Law Enforcement-Mental Health Learning Sites around the United States. Similar and additional information is accessible on the Bureau of Justice Assistance Police-Mental Health Collaboration Toolkit website (bja.ojp.gov/program/pmhc).

Although there is no single model of police-mental health collaboration that will meet the needs of all jurisdictions, you should custom-build your community’s collaboration by considering the essential elements recommended by Reuland (2010) that are reproduced in the text box below: 

Essential elements of specialized police-based responses. 

Source: Reuland (2010). 

3. Working with emergency hospitals. Those emergency hospitals (whether general hospitals or specialized psychiatric hospitals) to which police may take people in crisis are essential elements of the mental health system. You should meet with staff of these hospitals periodically to clarify expectations, develop workable protocols, and address problems and issues. For example, it should be clear when an officer must remain at the hospital and when hospital security can take over. It should be clear whether either the police or an ambulance is responsible for transporting a patient to another facility. Police commanders and specialists should work these matters out in advance, so that patrol officers do not have to argue and debate with hospital staff. Having a dedicated area in the hospital emergency department to handle people with mental illness can be helpful. 

4. Appointing police liaison officers. Issues related to people with mental illness need champions within the police department, or else they run the risk of falling through the cracks. Some police departments appoint an officer or commander to serve as liaison to the entire mental health community, including sitting on appropriate boards and committees. In addition, some departments appoint liaison officers for each mental health facility (hospital, shelter, group home, etc.) in the jurisdiction. These facility liaison officers can be particularly effective for reducing and preventing crimes, disorder, and calls for service at current and potential hot spots (see responses below under “Targeting Locations”). 

5. Establishing detailed policies and procedures. Rather than asking police officers to improvise responses to persons with mental illness, a written police department policy and set of procedures is recommended. These should cover, at a minimum, the circumstances under which referral for mental-health treatment, criminal arrest, or informal resolution should occur.[46], §

§ See International Association of Chiefs of Police (2018); Reuland, Schwarzfeld and Draper (2009).

6. Proactively addressing chronic mental illness-related problems. While there is great need to ensure that each critical incident involving a person with mental illness is handled properly, there is equal need to develop a systematic capacity for identifying chronic mental-illness-related problems, analyzing them, and developing and implementing preventive responses aimed at reducing future incidents.[47] For example, if in responding to an individual experiencing a mental-health crisis, you discover that police have dealt with this individual many times in the past, in addition to attending to the individual’s immediate needs for care, a deeper inquiry into the factors contributing to repetitive police contacts would be in order. This proactive, preventive response is reflected in several of the specific responses described below. 

Specific Responses to People with Mental Illness 

Improving the Police Response to Incidents 

7. Deploying specialized police officers. In recent years, the most popular approach to improving police response to incidents involving people with mental illness, and especially crisis incidents, has been specialization. Departments have seen the value of preparing specialist officers or even special units to handle these situations, relieving regular patrol officers of that responsibility. 

Ideally, a specialized assignment is one officers apply for rather than being involuntarily assigned to, but one that also entails careful selection criteria to ensure suitable candidates are selected.[48] This specialized assignment can be emotionally rewarding for officers, but it can also be perceived to entail greater physical, emotional, and career risks, so supervisors should be prepared to address those concerns.[49] 

The Memphis, Tennessee, Crisis Intervention Team (CIT) model is the most prevalent.[50],† It is recommended that a cadre of selected patrol officers (about 20 percent of those assigned to patrol but this can vary based on department needs) receive extra training (40 hours initially) and then serve as generalists/specialists—they perform the full-range of regular patrol duties, but respond immediately (from anywhere in the city) whenever crisis situations occur involving people with mental illness. In those situations, these officers assume on-scene command as soon as they arrive. They are trained to handle the crisis situations as well as to facilitate the delivery of treatment and other services. In particular, they become knowledgeable about voluntary and involuntary commitment, plus they become well known to professionals in the mental health community, facilitating the delivery of treatment and other services to the people in crisis.

†  “Specialized Policing Response” (SPR) programs is another term used for CIT-type programs, although they might not adhere as closely to the Memphis CIT model (Pelfrey and Young, 2020).

A review of the evidence from CIT programs have shown some promising results. The CIT model has been shown to improve officers’ attitudes and actions.[51] It can decrease stigma towards people with serious mental illness, enhance officer self-efficacy, and increase their knowledge of mental illness. Additionally, when CIT officers interact with people suspected of having a mental illness, they are more likely to divert these individuals into mental health treatment and services and less likely to arrest than non-CIT officers.[52] However, some studies have reached opposite or neutral conclusions.[53] 

While not conclusively demonstrated, CIT-trained officers tend to use lesser amounts of physical force to gain compliance from mentally ill persons without increasing the risk of injury to either the officer or the mentally ill person.[54] 

Evaluating the effectiveness of CIT programs is difficult given that the implementation of the CIT program varies from department to department.[55] The consistent feature of the CIT program across organizations is the 40-hour training requirement. 

There are several limitations of the Memphis CIT model for smaller agencies.[56] First, in small agencies, at least half of, if not all, officers would need the specialized training so that a CIT officer would always be on duty; under such circumstances, selecting officers for CIT could not be as selective as in Memphis, since every officer or every other officer would be selected. Also, CIT officers in a small agency would need more time to gain substantial experience in handling people in mental health crisis, simply because the volume of such situations would be limited. In addition, a key factor in the success of the CIT model is networking and collaboration between police and mental health service providers. In a small jurisdiction, however, such providers may be absent, and certainly not available around the clock. Consequently, the CIT model may not be as effective in smaller jurisdictions as it is in larger ones, and not as viable in rural jurisdictions as in urban ones.[57] 

8. Deploying specialized nonpolice responders. An alternative to specialized police response to calls involving people with mental illness is a specialized nonpolice response or co-responder model (sometimes referred to as mobile crisis teams or crisis response teams‡). This usually involves response by social workers/mental health clinicians.[58] These approaches recognize that mental health professionals have skills and knowledge that most police officers do not and cannot realistically acquire through their training.

‡ The Crisis Assistance Helping Out on the Streets (CAHOOTS) program in Eugene, Oregon; the Therapeutic Transportation Pilot Program in Los Angeles; the Rapid Integrated Group Healthcare Team (RIGHT) in Dallas, Texas; the Support Team Assisted Response (STAR) in Denver; and the Law Enforcement Assisted Diversion (LEAD) program in Seattle, Washington, are among such programs (Sofer, 2021).

The co-responder model in which police officers and mental health professionals—and sometimes paramedics[59]—respond jointly to incidents involving mentally ill people is the next most popular model after CIT. The co-responder model further recognizes that situations involving people in mental health crisis can be dangerous and may require the use of physical force and/or enforcement of the criminal law, capacities possessed by police officers, not social workers or mental health clinicians. Research on co-responder models has shown similar effects to that of CIT. Co-responder models have been shown to result in one or more of the following: 

• increased officers’ knowledge of mental health illnesses and their self-efficacy in dealing with people with mental illness
• increased likelihood that the situation will be resolved on the street rather than through emergency mental health detention
• increased voluntary admissions to treatment
• reduced police time spent on scene and at emergency rooms
• improved collaboration and information sharing between police and mental health clinicians
• improved perceptions of mentally ill persons in how fairly they were treated during the interaction with co-responders
• improved access to mental health, social service and community resources for persons with mental illness.[60] 

Outcomes regarding use of force, arrests, and injuries have been inconclusive, but some studies have revealed substantial reductions.[61] 

Implementing these nonpolice and combined models can be even more complicated and challenging than the Memphis CIT model because social workers and mental health professionals are not routinely available 24 hours a day nor typically dispatched to emergencies in the field. Nevertheless, models of this type have been used in various major cities across the United States, United Kingdom, Australia[62], and Canada. These nonpolice alternative programs do not typically handle as high a proportion of calls involving mental illness nor are they able to respond to incidents as quickly as can CIT programs, but they may resolve a greater proportion of incidents at the scene or through referral, whereas the CIT approach tends to rely on transporting the person in crisis to a treatment location. 

Among the key issues you should consider in developing and managing a co-responder program are the following[63]: 

• whether the co-responder team will only respond to requests for assistance or proactively seek out persons to assist
• which types of citizen- and officer-generated requests for assistance the co-responder team will handle
• where within the jurisdiction the co-responder program will concentrate its resources
• how police and mental-health treatment records will be shared
• whether to provide joint training in responding to critical incidents
• whether police and mental-health clinicians will share office space or work from separate offices
• whether police and mental-health clinicians will ride together in the field or respond independently to critical incidents
• whether mental-health clinicians will assist police in person or via telephone/video link
• how police and mental health clinicians will understand their respective interests and professional standards
• what criteria to apply in determining the response to an incident (i.e., arrest, voluntary mental health treatment, involuntary mental health commitment, home/community treatment, no action)
• what performance standards should apply
• when mental health clinicians will work and what protocols will apply when they are unavailable. 

The choice between police and nonpolice specialized responses largely depends on available resources. If your jurisdiction has the resources, it should employ both. Where available, the services of a trained clinician at the scene of a mental health crisis seems to help divert people away from the criminal justice and emergency medical systems in favor of informal handling and referral to nonemergency treatment providers. In most cases, however, sufficient social work/mental health resources are rarely available to provide prompt mobile response to a majority of incidents. In these situations, specialized police response seems to provide a number of positive outcomes, as noted above. Manchester Police in the United Kingdom developed a variation on this response: they hired a mental health clinician into the police agency to help identify chronically mentally ill persons who were coming into frequent police contact, and work to develop customized responses to assist them.[64] 

In developing a co-responder model, pay careful attention to clarifying the respective roles and objectives of police officers and mental-health clinicians. Coming from different occupations, with differing priorities and practices, police and mental-health practitioners will not easily reconcile those differences without clear policies and guidance.[65] 

9. Training public-safety call takers. Because most police interventions with mentally ill persons are initiated by a citizen call to a public-safety communications center, improving call takers’ ability to recognize possible mental illness as a significant contributing factor in the request for assistance can increase the likelihood of bringing mental-health resources into the situation from the outset. Some communications centers provide their call-takers with specialized training in mental illness recognition and referral. Others have embedded mental-health professionals in the communications center, available to take over the call or to otherwise advise the regular call-takers. Yet others have established collaborations with mental-health or crisis-intervention provider organizations that allow call-takers to either transfer the call to that organization immediately, refer the complainant to the organization, or have the organization reach out to the caller.[66] In some instances, there is no need to dispatch a police officer at all. 

10. Training generalist police officers. All police officers should receive at least some specialized training in interacting with mentally ill people, training that includes the following: 

• recognition of the signs and symptoms of common mental illnesses
• correcting false assumptions and implicit biases relating to mental illness
• how to communicate effectively with mentally ill persons, particularly those in an acute crisis
• police authority, response options, and resources available to them.[67] 

Training should be regarded as a promising method for improving the police response to incidents involving people with mental illness, but it is not sufficient in itself.[68] Additionally, because police officers’ attitudes toward people with mental illnesses are influenced by exposure to such persons in a personal way[69], in order to build empathy, ideally, police recruits should be introduced to a variety of people with mental illnesses, but outside the context of a mental health crisis. Some police academies use role-playing—sometimes with trained actors—to teach police officers how to handle incidents involving people with mental illness.[70] Some online training courses have also shown evidence of effectively improving police officers’ abilities to de-escalate situations involving people with mental illness.[71] Proper training typically integrates lecture, discussion, tours of mental health facilities, and role-playing.[72] 

Many states now require that police officers receive pre-service and in-service training in dealing with people with mental illness, with some departments making CIT training mandatory for the entire department.[73] Currently, the popularity of CIT training has expanded to over 2,700 police agencies across the country. The curriculum of each program varies with some agencies implementing only the 40-hour minimum to some agencies employing specific CIT teams. Other training curricula, such as Mental Health First Aid®, while less extensive than CIT, can nonetheless provide new officers with useful knowledge about interacting with mentally ill people. One rule of thumb is that all patrol officers should receive the level of training offered in courses such as Mental Health First Aid, and about 20-25% of patrol officers should be CIT-trained.[74] 

Training can improve officer’s attitudes towards dealing with persons with mental illness[75], but there have been contrary findings as well[76], so this objective is not an assured outcome of training. CIT-trained officers tend to be better able to identify mental health symptoms in suspects, and that CIT-trained officers are more likely to transfer suspects into appropriate mental health treatment services.[77] However, a change in attitudes does not necessarily reflect a change in behavior. Training that exaggerates the danger involved in police encounters with people with mental illness can lead to premature and excessive use of force, but realistic training with role-playing can reduce police use of deadly force when dealing with emotionally disturbed people.[78] Training generalist patrol officers in dealing with people with mental illness is necessary and likely helpful, but will not by itself completely change police encounters with mentally ill people.[79] 

11. Providing more information to patrol officers. Regular patrol officers called upon to handle incidents involving people with mental illness can benefit from at least two types of specific information. One is information about clinics, shelters, and mental health services that are available in the community. Armed with this type of information, officers are better able to refer people with mental illness to agencies better suited to provide treatment and other services, and/or to provide such information to family members or other guardians. You might provide this information to officers via brochures, printed referral agency directories, the agency’s online intranet or web site, or a smartphone app. Ideally, officers would have real-time information as to whether agencies have the capacity to provide services immediately so that officers’ time is not wasted. 

A second type of valuable information for patrol officers is an individual’s history of mental illness. People who repeatedly report fictional events, for example, or who have had mental health crises that led to violent encounters with officers, might be logged in a database or flagged in the department’s dispatching system. 

A third type of enhanced information that could improve officers’ response to people in mental health crises is video streaming of the scene—and, ideally, of the person in crisis—that is accessible to officers prior to their arrival on scene. The Chula Vista, California, police have been using aerial drones for this purpose: they enable responding officers to see what people are doing at the scene minutes before police arrival. This improves officers’ ability to plan their entry to the scene and, if needed, to mobilize other resources, both of which increase the likelihood of a safe and effective response to the crisis.[80] 

The purpose of this information would be to forewarn an officer who subsequently is dispatched to a chronic caller’s address, or who encounters a potentially violent person. Otherwise, especially in a large department, officers find themselves at a disadvantage dealing with people whom they know nothing about, despite the fact that the people have a history with other agency officers.[81] Knowledge of past behaviors, symptom history, and potential triggers can be beneficial in equipping officers with what to expect once on scene. 

Of course, the compilation and dissemination of this type of information raises some legal and privacy issues that have to be carefully addressed. Another concern is labeling—advance information about a person’s mental illness history might prejudice an officer’s decision-making, but proper training and adherence to protocols should reduce this risk.[82] 

12. Using less-lethal weapons. Police officers can resolve most tense and threatening situations involving people with mental illness by maintaining a calm demeanor, using good verbal and nonverbal communication, and using proper tactics, but when those techniques fail, it is crucial to have additional less-lethal force alternatives. Too often in the past in encounters with people experiencing mental health crises, officers have used poor tactics and then resorted to deadly force.[83] Today, the practicality and effectiveness of less-lethal police weapons, including pepper spray and stun guns, have improved and you should explore obtaining those that are reliable and affordable. In particular, less-lethal weapons offer police officers alternatives in situations in which a person with mental illness is wielding a knife or a blunt object in a threatening manner, or when the person’s strength threatens to overwhelm the officer. Your agency should enact clear policies and procedures to guide officers’ use-of-force decisions and ensure that the least- necessary force is used.[84] 

13. Withdrawing police from some incident scenes. In rare instances, the presence of police at a crisis scene can increase the risk of physical harm rather than decrease it, as intended. For example, in events commonly referred to as “suicide by cop,” a person with suicidal intentions summons the police in hopes of inducing the police to take their life.§ Some police agencies have decided that unless another person’s life is at risk, withdrawing police from the scene eliminates the possibility of a “suicide by cop” without substantially increasing the risk of the person taking their own life. If this policy—sometimes referred to as “tactical disengagement”—is adopted, it should be supported by professional mental-health outreach to the individual and his or her family.[85]

§ While it has long been debated whether the desire to end one’s life is inherently a manifestation of a mental disorder, in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, preliminary steps have been taken to recognize suicide behavior disorder as a mental disorder.

Improving the Efficiency and Effectiveness of Mental Health Care 

14. Initiating assisted outpatient treatment. Many people with serious mental illness live in the community rather than in institutions. For a variety of reasons, they often fail to adhere to prescribed treatment, including medication. In most states, if a person is under court jurisdiction, a condition of remaining in the community can be compliance with prescribed treatment. When strong mechanisms are in place to encourage adherence to prescribed treatment, problems are reduced.[86] Assisted outpatient treatment (AOT), also called outpatient commitment, uses enforcement of treatment plans by mental health workers or others (sometimes including police) to increase compliance. Police can support AOT petitions either through testimony or by providing police records of prior interactions with the mentally ill individual. Properly done, AOT has been shown to reduce hospital readmissions and length of stay, homelessness, arrests and incarcerations, victimization, and violent behavior, and to increase treatment compliance and long-term voluntary compliance with treatment plans.[87] 

15. Establishing crisis response sites. Crisis response sites are facilities where police can transport people in mental health crisis, as an alternative to the general hospital emergency room or jail.[88] They are usually located within hospitals. They serve as a central drop-off point, providing inter-agency collaboration, both mental health and substance abuse services, a no-refusal policy for police (although this does not mean that inpatient stays are guaranteed), and streamlined intake procedures (usually 30 minutes or less for officers). These features have resulted in reduced police officer frustration and reduced reliance on arrest and jail to deal with people with mental illness. It has also increased consumer satisfaction.[89] 

16. Establishing jail-based diversion. It is inevitable that some people with mental illness will be arrested for minor crimes and disorder. When these people get to jail and are determined to be suffering from serious illness, they can be diverted immediately after booking (with special conditions), as soon as the case is reviewed for prosecution (through deferred prosecution with conditions), or as soon as the case comes to court (by summary probation with conditions).[90] Diversion benefits the jail by removing detainees with mental illnesses who require services that the jail probably cannot provide, and they benefit the detainee by diverting them from jail to treatment. Diversion can also result in fewer future arrests and less time in jail.[91] For these diversion options to be successful, though, resources must be in place to supervise release conditions and provide treatment. Otherwise, diversion will just contribute to the deinstitutionalization/ criminalization revolving door. 

17. Establishing alternatives for transporting non-violent mentally ill persons to mental health facilities. The time and consequent cost of having police officers do most of the transporting of persons to mental health facilities, as well as the time officers spend waiting in those facilities, is tremendously high.[92] Either by policy or law, police should be relieved of much of this responsibility in cases where the mentally ill person shows no sign of violent behavior and their disorder is not known to be associated with violence. Simply reducing the time demands on officers is likely to increase their willingness to seek a mental health response for the individual, rather than a criminal arrest or no action. 

18. Establishing mental health courts. When people with mental illness do go to court for committing minor offenses and disorder, the experience is often unsatisfactory, because most prosecutors and judges lack the experience and expertise to handle such cases effectively, including knowledge about mental illness and awareness of treatment options. When defendants with mental illness receive long incarceration sentences or unsupervised probation, they are less likely to receive the mental health treatment that could benefit them and reduce their risk of reoffending. Specialized mental health courts have ready access to mental health professionals, programs, and other resources that can be tailored to each defendant’s mental health needs.[93] Mental health courts can reduce recidivism and improve defendants’ quality of life, but in order to be effective, consistency and quality relationships with providers are important.[94] 

Concentrating and Customizing Interventions for Those Who Repeatedly Come into Contact with Police 

Because, compared to the general population, people with mental illnesses are more likely to come into contact with police, whether as complainants, victims, or offenders, if you are able to identify these repeat-contact people—and/or the places in which the police contacts frequently occur—you should then seek to develop and implement customized and concentrated interventions that are aimed at reducing the need for frequent police contact with these individuals. 

19. Protecting repeat victims. Because previous victimization is generally the best predictor of future victimization, try to identify repeat crime victims who show signs of mental illness. During mental health screening processes, be alert for signs of prior criminal victimization, including by asking persons with mental illness about past victimization. Once repeat victims have been identified, try to learn why they are vulnerable to victimization.† For example, if a person with mental illness is a repeat victim, an abusive caregiver might be uncovered. Or it might be that the person frequents risky places or engages in risky behaviors. It is also possible, of course, that the crimes reported by the person with mental illness are only imagined. Identifying any of these “causes” could lead to solutions that reduce or even eliminate future victimizations. Possible preventive measures include ensuring the person receives proper treatment for their mental disorder and any accompanying substance abuse, lives in safe housing, is protected by responsible caregivers, is engaged in prosocial activities, and has secure finances.[95], ‡

† See Problem-Solving Tools Guide No. 4, Analyzing Repeat Victimization.

‡ See Baltimore County Police Department (1998) and Durham Constabulary (2018), for case studies of police responses to frequently victimized people with mental illness.

Alternatively, be alert to the possibility that people with mental illness might habitually victimize others—caregivers, family members, employers. 

From the standpoints of equity and prevention, it is important to provide information and services to people with mental illness who are crime victims, as well as to people who are victimized by people with mental illness.[96] In either instance, standard victim services should be provided as well as information specifically associated with mental illness. A crime victim with mental illness may experience more trauma than normal, including the possibility that memories of past abuses can be triggered. Similarly, family members of a person with mental illness who are victimized by that person may experience extra fear, anger, remorse, or even guilt because of the intimate relationships involved.§

§ More information for and about victims is available from the National Organization for Victim Assistance, the National Center for Victims of Crime, the U.S. Justice Department Office for Victims of Crime, and the National Alliance for the Mentally Ill, among others.

20. Focusing on repeat offenders. It is widely recognized that a relatively small proportion of offenders commit a relatively substantial proportion of offenses.† If people with mental illness are identified who are repeat criminal offenders, attention should be focused on them.[97], ‡ This may involve criminal charges, involuntary commitment, better guardianship, court-ordered medication, restraining orders, or any number of other techniques, depending on the circumstances. The key is to focus attention on anyone who is responsible for a disproportionate share of a problem.

† See Problem-Solving Tools Guide No. 11, Analyzing and Responding to Repeat Offending.

‡ See San Diego Police Department (1998), Charlotte-Mecklenburg Police Department (2001), Cleveland (UK) Police (2007), Houston Police Department (2010), and Greater Manchester Police (2015), for case studies of police responses to chronic offenders with mental illness.

Similarly, there may be community members who commit repeat crimes against people with mental illness. These might include assault, theft, harassment, or fraud. The perpetrators might be caregivers, family members, neighbors, or relative strangers. Because people with mental illness who report crimes are sometimes treated with skepticism and suspicion, those who repeatedly victimize them may be more difficult to identify than should be the case. Police efforts to identify and target these people should be given high priority, though, because they are repeat criminals and because of their victims’ particularly vulnerable nature. 

Chronic disturbances involving people with mental illness are among the most frustrating situations for police because there are few options available to officers. If a person with mental illness is merely being loud, being annoying, or acting strangely, involuntary civil commitment is not usually an option, because the person is not putting himself or others in danger. In response to any particular incident, officers might attempt informal de-escalation, look for a guardian, command the individual to cease or leave, or make an arrest for disorderly conduct. When the same person engages in the same behavior repeatedly, however, officers may run out of options quickly, especially if the jail tightens its criteria on accepting people with mental illness. The situation is exacerbated if there are complainants who expect the officer to do something. 

21. Focusing on complainants responsible for repeat calls for service. In addition to chronic disturbances, some individuals are responsible for placing a disproportionate volume of calls for police service. In the case of people with mental illness, this might involve a large number of false, imaginary, or trivial calls. If you can identify and target these repeat complainants, you may be able to reduce the volume of calls substantially.§

§ See Georgetown Police Department (1998), Ithaca Police Department (1998), Overland Park Police Department (1998), and Cleveland (UK) Police (2011) for case studies of police responses to a chronic complainant with mental illness.

In Lancashire, England, police collaborated with a wide range of other agencies to identify and proactively assist frequent callers to the police, so-called vulnerable persons. As a result, calls to police were reduced significantly and the service to vulnerable persons improved.[98] Lincoln, Nebraska, police collaborated with mental health providers in a community-based peer support program (REAL) to connect mentally ill persons with longer-term support services in the wake of a police contact. The program is administered by the state mental health association and the peer assistance is provided by trained persons who themselves have been treated for mental illness. The police role is largely one of referral and helping make contacts with service organizations. A program evaluation showed that persons referred to REAL had fewer mental health contacts with police and fewer involuntary mental-health commitments in future years, although it did not appear to affect future arrests.[99] 

A common theme running through many police efforts to address problems relating to the chronically mentally ill is that when police officers are personally familiar with chronically mentally ill persons and have earned their trust through repeated compassionate interactions with them, this increases the likelihood of these individuals voluntarily receiving needed assistance and treatment.[100] 

22. Focusing on places where police frequently have contact with people with mental illness. Crime, disorder, and calls for service tend to be concentrated in a subset of all locations in any jurisdiction.† This general pattern seems to hold with regard to problems associated with persons with mental illness.[101] Locations commonly involving police interactions with people with mental illness could include psychiatric and general hospitals, , shelters, group homes, and some private residences. 

† See Problem-Solving Tools Guide No. 14, Understanding and Responding to Crime and Disorder Hot Spots.

Of course, identifying hot spots is just the first step. Once a chronic repeat call location is identified, it is important to analyze the situation to determine the nature of the calls and why they are occurring, as a prelude to implementing tailored responses. The situation might involve a single chronic false complainant, a poorly managed group home, or a hospital with inadequate security staff. Baltimore police and mental health clinicians collaborated to proactively identify residents living on several high-crime blocks who were experiencing mental health and substance abuse problems, and to offer and provide them appropriate treatment services. This unconventional approach showed promise in both providing needed services and improving police-community relations.[102] 

23. Regulating facilities more effectively. One effective approach to a mental health facility hot spot might be to apply or enhance external regulation. Licensing regulations, civil injunctions, nuisance abatement orders, staff training, and facility redesign might be used to improve the care of mentally ill patients or residents in residential care facilities.‡ 

‡ See San Diego Police Department (2000), Lancashire Constabulary (2004), and Durham Constabulary (2018) for case studies of police responses to inadequately managed residential care facilities for people with mental illness.

24. Arresting people with mental illness. Except when people with mental illness commit serious crimes, arrest is generally not an effective response. When police arrest people with mental illness for minor crimes and disturbances, it is frequently because they cannot identify any other options and are desperate for a short-term solution. Even so, jails often refuse to accept the arrestees, resulting in their almost-immediate release. Long-term solutions are not usually reached either, because prosecutors often refuse to file charges. Making arrests in these situations typically frustrates both police officers and the people who get arrested, while accomplishing little or nothing. In those instances when arresting someone with mental illness does result in jail and prosecution, police may feel satisfied that a short-term solution has been achieved, but evidence indicates that the costs are considerable[103], as explained below. 

25. Incarcerating people with mental illness. People with mental illness may end up in jail awaiting trial, in jail serving a sentence, or in prison serving a sentence. They end up in jail and prison in large numbers—it is estimated that about half of state prison inmates and about two-thirds of jail inmates have some type of mental illness, with about one-fourth of them having a serious mental illness.[104] Sheriffs, jail administrators, and prison wardens regularly express their frustrations over the stresses and strains caused in their institutions by the inappropriate criminal justice incarceration of persons with mental illness. 

Neither jail nor prison is a good setting for mental health treatment, if such treatment is even available. People with mental illness often get worse while incarcerated, and tragedies involving victimization and suicide are too common.[105] In the long run, criminal justice incarceration of the mentally ill harms the lives of those people, interferes with the proper operation of jails and prisons, and accomplishes little or no long-term solution to the original crime-and-disorder problems that led to arrest and incarceration in the first place. Referral, treatment, and civil commitment for people with mental illness should be preferred over arrest and criminal justice incarceration as responses to minor crime-and-disorder problems. 

26. Ignoring the needs of people with mental illness. Police officers sometimes get frustrated by people with mental illness, and respond by doing nothing. They may ignore disruptive behavior, hoping that no citizen will complain, or refuse to respond when chronic complainants call to report a crime, or try to trick or distract a person whose behavior seems driven by mental illness. The real purpose of these responses is to extricate the officer from the immediate situation, leaving the problem unresolved. Doing nothing, while understandable when officers have little training about mental illness or few viable response options, nonetheless demonstrates poor policing.