Many years ago, I worked for a public mental health agency as a crisis outreach therapist. My professional responsibilities included going to people’s homes—anything from a tent under a bridge to a mansion in the most prosperous area of the city—when a person was in mental health crisis. This usually meant someone in the throes of a psychotic or manic episode; or they were suicidal, homicidal or aggressive due to a mental disorder. Sometimes there was an identifiable cause for the incident: The person couldn’t afford rent, was about to be evicted or had stopped taking psychiatric medications. These were people who, at least in their minds, were about to lose everything.
Most of the time I worked independently from law enforcement, because things were not at a level of danger that I needed their help. When there was a threat or a creditable potential for danger, I gladly asked for law enforcement help.
Law Enforcement and Mental Health Partners
Somehow, much of the public assumes that if a 911 caller reports a person in psychiatric crisis, then, no matter the circumstances, police should not be dispatched. These people maintain that a mental health professional should instead go alone, on the grounds that police aren’t necessary and their presence might escalate matters.
This is wrong for a couple of reasons. First, an assertion that someone is mentally ill is not a diagnosis. On what grounds should the 911 telecommunicator trust the caller? Second, mental illness, particularly when combined with intoxication, can make a person more dangerous, not less. That the person’s violence may be driven by delusional ideas, profound terror or a flashback to previous traumatic events does not change the damage a bullet, club or blade will inflict.
When I would call police for back-up, we would usually stage first. The officers would ask me to tell them why I was there, what I hoped to accomplish, how I meant to do that and why I requested their help. They would confirm any known history of violence. They would also ask me if I had any history with the individual and if I was aware of any patterns of behavior that might be precursors to assault. Finally, they would ask whether I was aware of the person owning or carrying any weapons. When they assessed the situation was safe enough for me to take the lead, they would provide instruction something like this:
“Okay, Mr. Amdur, here’s what we will do. You’ll knock on the door. We’ll be providing cover for you. You’ll stand on the hinge side of the door, so that if they immediately try to attack, you won’t be directly in the center of the doorway. In that case, we’ll protect you. If, on the other hand, they’re willing to talk with you, stay back. Keep your distance. If you believe yourself in danger, you’ll say, ‘This is a problem,’ as you take two big steps back out of the way, at which point we’ll take over. If we believe you’re in danger, one of us will say, ‘Problem now.’ You’ll take two steps back out of the way and we’ll take over. In that case, until they’re in custody and safe, you will not further involve yourself—neither physically nor verbally—unless directed by us. In that case, we’ll use very specific language, and you’ll follow our directions. Is that clear?”
I would affirm and then they would ask me to repeat their instructions to ensure I had fully understood the plan.
In recent years, this sort of professional collaboration has been formalized under the model of mental health co-responders (MHCR). These are trained medical healthcare professionals attached to a law enforcement unit to accompany them on calls involving people apparently suffering from mental disturbance. On some calls, they stage nearby, offering law enforcement advice. In other calls, once law enforcement ensures the scene is safe (enough), they turn over the lead in communication to the mental health professional. Sometimes the teams engage the individual together.
The classic models of both psychotherapy and social work seek to maintain the privacy and dignity of the subject or patient in question. Strict boundaries are established between professional roles on scene, e.g., law enforcement, probation/parole officers, mental healthcare providers and medics. Doing this in the field, under often tense conditions, requires poise and practice. Before implementing such a model into your agency, weigh some consideration:
- Is the mental-health co-responder is a police employee, an outside consultant or an employee of another agency? This can have bearing on such things as legal liability, insurance protection and confidentiality. Consultants and those from outside the agency might require more strict standards on confidentiality.
- How should subjects be informed of their rights?
- How will interactions be ended if the situation is no longer emergent, but would still benefit from therapeutic or medical attention? In other words, when the mental health co-responder and police are successful in crisis intervention, at what point is the case over? Remember: An MHCR is not functioning as a therapist.
Humility must not be one-way.
Mental health professionals must understand the job they are purporting to assist. Anyone who volunteers or is hired to be a MHCR should do three things before getting into the field:
- Go on ride-alongs with law enforcement officers.
- Participate, as best as one’s physical condition permits, in law enforcement defensive tactics training—at least once.
- Most importantly, enroll in a citizen’s police academy. This will provide you with a sense of what the job is and how quickly—split seconds—one has to make decisions. You will see firsthand how easy it is to make a mistake and how dire the consequences can be.
The Law Enforcement Officer’s Role
Humility must not be one-way. Too often, I hear law enforcement refer to mental health interventions as “hug-a-thug” programs. The truth is, every officer will routinely interact with mentally ill and emotionally disturbed citizens, whether they want to or not. Some officers are not only more effective than others, they have a calling for working with psychologically distressed subjects. This is similar to how other officers are particularly suited to SWAT, K-9 or detective work. Adept officers are who you want with the MHCR team.
MHCR should be a program, whether attached to the Community Service Officer (CSO) division or part of the Crisis Intervention Team (CIT), encompassing a dedicated group of officers who work with the MHCRs. They should be a specialized unit and train as such.
Officers on this team should receive specialized training beyond de-escalation and CIT. I suggest they:
- Visit psychiatric hospitals, day treatment facilities and mental health units within the corrections environment (the mirror image of ride-alongs) and observe mental health professionals and correctional officers, doing their work. This also gives them an opportunity to meet individuals suffering from mental illness outside the usual emergent situations.
- Take a basic hostage/crisis negotiation course, along with MHCR partners, such as the 40-hour course offered by the FBI. A potential advantage of this is that the MHCR program can be a preparatory unit for hostage and crisis negotiations. Prospective members of the team will already have a lot of experience—and training—communicating with emotionally disturbed individuals.
When mental health providers partner with law enforcement in a strategic and thoughtful manner, it’s possible to improve outcomes for those suffering from mental illness, substance abuse disorders and other emotional/cognitive impairments. A mental health professional acting as an on-scene consultant to both the police officer and to various involved citizens can reduce the likelihood of the situation escalating to violence. This, rather than the fantasy of eliminating law enforcement and turning such situations exclusively over to the mental health system, actually has the potential of enhancing public safety over the long term—particularly for those most at-risk.
CAHOOTS (Crisis Assistance Helping Out on the Streets) is another model. It sends teams of social service professionals into the field without law enforcement support. These teams, usually consisting of a medic and trained mental healthcare provider, perform outreach and emergency calls for service where no immediate threat to life is present. These are typically calls for someone identified as mentally ill, emotionally disturbed or in dire need of compassionate and informed assistance.