WESTBOROUGH, MA April 7, 2018 The myths of mental illness come up over and over when criminal justice reform is discussed. Here in Massachusetts a significant update of the Criminal Justice laws has just been passed and await Massachusetts Governor Charlie Baker’s signature.
In truth most criminals are not mentally ill. The question is how do so many people who are mentally ill wind up in prison populations? Jail diversion projects are being introduced from coast to coast and will directly impact the number of people with mental illness who are in the state prison and county jail systems. It has worked elsewhere including San Antonio, TX. We are led to believe that as much as
40 percent of the inmate prison population has some form of mental illness although I do not dispute this. The stigma associated with being “mentally ill” calls for added resources for treating them. Just as resources are provided for those with diabetes, atrial fibrillation and COPD. These patients are not stigmatized for the maladaptive choices they make that may confound the medical complexity they experience and its cost to society. Some of the worst cases of COPD I have worked with continue to use tobacco products. Similarly, those with uncontrolled diabetes may require diseased-related surgical amputation of toes, foot, legs, yet remain non-compliant with checking their blood glucose. Why? They are not stigmatized – unless they are obese.
Each time we see something horrific we automatically assume the person to whom the acts are attributed “must be sick”. These notions have been discussed over and over in these pages. In truth, mental illness has less to do with aggression toward people than crimes such as petty theft and other nuisance offenses like disorderly conduct and panhandling. My sense is that whenever an arrest is made the differential diagnosis is all about the base – and underlying addiction and substance abuse must be considered and treated.
In the 1970’s the Massachusetts state hospital system had been deconstructed and was taken out of the continuum of care. The chronically ill fell off the treatment radar and went rogue. Importantly in Massachusetts, this triggered the swing away from hospital-based care to the community health centers that became the front line for those in crisis. At this point the myth of mental illness began its insidious transformation and jail became the containment center in the absence of the venerable state hospitals. These insights are not new. The problem is that there are not enough treatment options including inpatient mental health care to make a viable change in the current trends.
“The short version is that while people with serious mental illness are slightly more likely to commit acts of violence than people without mental illness, the risk that it creates is pretty small compared to other known risk factors.” According to Joel Dvoskin “alcohol accounts for a great deal more violence than mental illness does.” APA, 2018
“So, when somebody feels depressed, enraged, insignificant, they have access to a firearm, maybe they’re drinking too much that night, maybe they just got fired and so on – it’s like this perfect storm of despair. ” according to Dr. Dvoskin. There are several states who are taking a close look at the removal of guns from people known to be violent or threatening – even prior to formal adjudication. Until now, there was little that could be done to remove weapons from a dangerous person until he committed a crime.
Here in Massachusetts the substance abuse problem and the mental illness problem are commonly lumped together. They are not mutually exclusive and I have posted previously that mental problems are often inflamed by substance use. We have come full circle in understanding the need for intensive resources that may have been lost by closing the hospitals and letting them crumble.
Dvoskin, J. (2018) Speaking of Psychology: Dispelling the myth of violence and mental illness Episode 27 American Psychological Association
WESTBOROUGH, MA – March 30, 2017 Police officers are being trained in crisis intervention techniques across the country and Canada. This training offers plenty of practice role-playing scenarios that come directly off of the call sheets affording a reality-based training opportunity. I recently spent time riding with members of the San Antonio PD mental health unit and have the greatest respect for the officers with whom I rode. In contrast, some departments regularly have highly trained clinicians riding with officers bringing expertise in mental illness and abnormal behavior across the thin blue line. It is thought that by sharing knowledge at working with unpredictable, drugged out, psychotic and delusional and angry who police encounter on a daily basis better outcomes may be achieved. No single model is best and all are still in the growing stages of establishing protocols for bringing those most disturbed individuals in from the margins. More and more officers are receiving CIT training every year.
The important part of crisis intervention training comes in the interdisciplinary relationships that are forged in by this methodology. Trust and respect between the police and its citizens builds slowly one person at a time. Community policing is not a new concept but fiscal priorities often prevent its full implementation. Just the same, there must be trust and respect between the police and the purveyors of crisis intervention and mental health risk assessment including doctors, nurses, and health care practitioners. This also takes time and training and the shared belief in the model.
“When officers are faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures,” according to Grace Gatpandan, spokesperson for the San Francisco Police Department
The use of force continuum belies each officer contact and guides the process when police are called upon to defuse a dangerous encounter. It is best that a mental health contact be made long before violent threats are made – long before terminal rage erodes personal judgment. The community policing doctrine affords this front end contact and encourages officers to know the people living on the beat.
POLICE ENCOUNTERS WITH MENTALLY ILL CITIZENS
The Boston Globe Spotlight series on police encounters with the mentally ill cites one distraught parent who was quoted “I only wanted the police to disarm him not shoot him dead.” Unfortunately for this family, when faced with lethal violence it is the behavior of the subject that drives the ship in terms of what will or will not happen. “When faced with a deadly situation, when there is a gun pointed at a cop, there is no time to go into mental health measures”. All too often people fail to see the cause – effect relationship between citizens with guns or other lethal weapons and the police officer response. The use of force continuum follows the principle of causation by guiding police decision making based on the level of threat.
What came first the threat or the police action? It is the primary action of the citizen the evokes the lethal response by police. If citizens dropped weapons and listened to police officer directives during these high energy and chaotic events there would be fewer deaths. To say they lack training in mental health is preposterous. Almost as preposterous as saying if they were better parents the mentally ill subject might not aim his gun at police or threaten his mother with a knife. No, the responsibility lies with the mental decision-making and subsequent behavior of the subject himself. If mental illness drives the violent behavior than all weapons and substance use must be carefully controlled and eliminated. When people attend psychotherapy sessions and 12-step recovery programs the proclivity for violence is greatly reduced. Inevitably, drug abuse is a co-morbid factor that alters perception and fuels underlying anger and violent tendencies. Who is responsible for this? When drug addition or alcoholism begin – all emotional growth including adult “problem solving” begins to fail until it is fraught with uncontrolled, impulsive violence. Rather than placing blame, greater emphasis on sobriety, counseling and developing emotional resiliency should be encouraged.
San Antonio, TX – February 25, 2017 Police officers wear many hats these days. I have spent the last few days learning about a specialized police unit in San Antonio Texas with the SAPD. The Mental Health Unit is a small, well-trained group of police officers who have committed themselves to the positive interaction of police officers and citizens with presumed mental illness. These police officers have a unique window into the chaos some families experience and the opportunity to bring calm to crisis (Sefton, 2014). In many cases, the correct response to this dysfunction should include a follow-up visit in the aftermath of the initial call when the dust has settled from the crisis that brought police to this threshold. When this is done it establishes a baseline of trust, empathy, and resilience. It works and I have seen it for myself.
Over a 15 year span the SAPD has established relationships and built a continuum of service whose mission is jail diversion and treatment for those who are afflicted with mental illness and substance abuse. The Restoration Center in downtown San Antonio is the nucleus for this “smart justice” model. It includes a mobile crisis outreach, 48 hour hospitalization, if necessary, a 90-day homeless shelter with job training e.g. resume building and job interview clothing, childcare and apartment units for those who qualify. As subjects move through the continuum they are provided referrals for individual psychotherapy, substance abuse education, Alcoholic’s Anonymous and the range of 12-step recovery programs. And everyone working there buys in.
Police are the front line responders to crises of all kinds. Asking them to serve in this new role presents a level of officer specialization like never before. Michael Sefton blog post 2013
I was given the complete tour and introduced to some key players including Ms. Amanda Miller coordinator at the Mobile Outreach program. The experience was enriching and illustrated the range of possibilities of humane care for those most vulnerable and often incompetent to make healthy choices for themselves. I wasn’t sure what to expect but I came away wishing I could have stayed on longer. The project diverts citizens into treatment in lieu of incarceration and also serves as an in-house resource where brother officers can turn when times get tough. And the mental health unit has seen its share of despair and self-destruction on their side of the blue line with sometimes insufferable results.
Police officers’ department-wide are trained in techniques of crisis intervention by the same two officers I was fortunate enough to ride with. For years, too many emotionally troubled citizens wound up among the incarcerated criminal population in state and county jails and did not receive the care they needed. In Bexar County, Texas, which includes San Antonio, with a growing population of over 1.5 million the main jail now has 800 open beds where it was once filled to capacity.
“CIT provides police with all kinds of useful resources. And when combined with adaptive strategic thinking, access to mental health professionals, and good leadership and good culture around applying the lessons of CIT, it can save lives,” said David M. Perry, an associate professor of history at Dominican University in Illinois and a journalist who has written about police violence and disabilities recently cite in a CNN story written by Liza Lucas in 2016.
San Antonio and over 22 communities share the services of the Restoration Center in downtown San Antonio
Culpability and Mental Illness
Are those with mental illness culpable for their behavior? Technically they are responsible unless determined to be unable to discern right from wrong based upon their mental incapacity. Does the fact that they suffer with conditions like bipolar depression, schizophrenia, or drug addiction render them not responsible? There is a national trend to view those with active mental illness as “not responsible” for their behavior largely due to the common belief that if the mental illness were being treated than the criminality in which they may be embroiled would plausibly diminish. Whenever something sensational happens like a school shooting or some other senseless criminal act people universally remark “he was sick” or “she must have been out of her mind” to do that. Not so fast say the social scientists where as the true prevalence of diminished capacity is quite rare.
I strongly believe that mental illness does not exempt citizens from responsibility for crimes they commit. I agree that alternative sentencing may be a powerful tool to bring these individuals into treatment. The substantive goal of streamlining encounters between police officers and citizens who suffer with untreated emotional problems belies the mission of these gifted officers and can teach others the role of discretion in mental health encounters. The reason for this is to deescalate potential violence and thereby reduce the incidence mentally disturbed persons who wind up in jail. This speaks to the importance of getting those most in need into treatment and off the streets sometimes by having a judge mandate they enter treatment. When charges are brought forth alternative sentencing models may offer leverage that include mandated treatment in lieu of jail time know as alternative sentencing. Studies show that those who remain in treatment are less violent than those who fail or drop out of treatment, Torrey, et.al., 2008. In Massachusetts where I served as a police officer for 12 years too many myths entangled the process of accessing treatment for the mentally ill. Officers were sometimes unsure of their options when a Q-5 prisoner was brought it and rarely made referrals for mental health care. Q-5 is the nomenclature used when referring to someone with a history of mental health issues – usually suicidal threats. These prisoners were required to be on one to one supervision when held in jail. At least that was the myth at the time I was serving.
Community Policing and Aftermath Intervention
I learned several important things about police officer interaction with citizens having mental illness. It is a complex and time consuming endeavor that requires follow up in the aftermath of a crisis. Police officers build credibility and trust in the process of this community interaction with citizens and those in the treatment continuum like physician Roberto Jimenez, M.D., a psychiatrist who has been there from the beginning in Bexar County. Dr. Jiminez began his career in Boston at the once revered Boston City Hospital where I completed my postdoctoral fellowship. He said to me “we had the national model in Boston….” referring to the system in place for police-mental health interaction in 1980. At the time, his service was utilized in conjunction with the state department of mental health and an active system of neighborhood health centers throughout the city. He referred to himself as the police psychiatrist. By then, the Massachusetts state hospital system had been deconstructed and was no longer in the continuum of care. The chronically ill fell off the treatment radar. Importantly in Massachusetts, this triggered the swing away from hospital-based care to the community health centers who became the front line for those in crisis. At this point the myth of mental illness began its insidious transformation. Jail became the containment locale in the absence of the venerable state hospitals for better or for worse. In January 2017, Massachusetts Governor Charlie Baker expanded number of available beds at the Bridgewater State Hospital for care of those in crisis.
Officers in the SAPD Mental Health Unit undergo specialized training in crisis intervention. Officers Stevens and Smarro teach the 40-hours class to police officers from across the country. All police recruits in the SAPD academy are given this training as part of their early law enforcement education suggesting strong support from the command hierarchy. Importantly, the CIT model teaches officers to return to the scene of their calls to make referrals for care as I observed in February. The follow-up call is key in rebuilding trust and illustrates the commitment in police-mental health care continuum. Just as importantly is the relationship created among police officers and direct service personnel like Dr. Jimenez who share the understanding of what can be done for those most in need.
Ostensibly, building relationships with network psychotherapists, physicians, addiction specialists, court judges, and other support service like Child and Family Services is essential. Officers Stevens and Smarro spent hours on the telephone reaching out to the network of physicians, judges, hospital admission personnel and brother officers all in the service of a single case they picked up one evening while on an overtime patrol shift. Had they not caught the call on that night the complainant family may have flown under the law enforcement radar forever and a 33-year old depressed and delusional male may have become increasingly morose perhaps violent. Instead he was put into treatment with the real eventual possibility of receiving social security disability payments to help he and his family and the treatment he needs to begin life again. Next is a strong conviction in what you are being asked to do. It is necessary and constitutive work that often flies below the radar and out of the headlines. It requires patience, flexibility and the right temperament. And finally, officers need to follow-up on calls and build bridges and trust with those they serve including members on the same side of the thin blue line.
Setting the San Antonio program apart is the routine followup in the aftermath of high intensity calls such as domestic conflict or the run-of-the mill calls to houses where families are struggling with under employment, substance use or any number of social problems. A brief second or third visit may just do the trick to hook in a family or individual otherwise in the margins of society bringing forth growth and human contact.