Building on the Evidence

Police–citizen encounters that end badly—with someone getting injured or killed—have lately captured media attention in the United States. These events have focused public attention on the troubled relationship between law enforcement and urban communities plagued by violent crime, entrenched poverty, and a legacy of racial discrimination. Within that larger social context are complex situations that police officers often face when called to intervene with people who appear to be mentally ill and who might pose a risk of harm to themselves or the public. In these encounters, police act not only as public safety officers but also as informal social workers, emergency health-care workers, and providers of access to treatment services (Wood, Swanson, Burris, and Gilbert, 2011). The question of when to use force in such cases, as well as how best to avoid or minimize its use without compromising officer safety, is an ongoing challenge for law enforcement training, practice, policy, and community relations.

The U.S. Supreme Court’s recent decision in City and County of San Francisco v. Sheehan (2015) highlighted complex legal issues related to these matters as well. The court held that officers who forcibly entered the room of a woman with a mental disability and shot her are entitled to qualified immunity from a lawsuit seeking redress for the woman’s injuries.The court left undetermined the broader question of whether police officers who arrest or detain and transport a person with a mental illness are subject to ADA Title II requirements to provide reasonable accommodation of persons with disabilities. In this policy essay, I discuss several underlying issues that are raised by Morabito and Socia’s (2015, this issue) study on the question of potentially increased risk of injury when police officers encounter persons in the community who seem to suffer from acute psychiatric symptoms or substance intoxication.

Within the broad range of police encounters, special attention is needed to understand and inform encounters with persons with mental illnesses—a challenging interface during which police and persons in mental-health crisis may both feel vulnerable, raising the risk that the exchange could involve use of force or injury. Officers’ presumptions about the dangerousness of persons in mental-health crisis are likely to have a strong influence on their response, including the extent to which they use force during those encounters. There have been longstanding concerns that persons with mental illnesses face prejudicial treatment by police largely for being misunderstood and stigmatized, and that they are disproportionately vulnerable to police use of force and injury for those reasons. Little definitive evidence exists, however, to support or discount this hypothesis.

New Evidence on Injury During Police Encounters with People with Mental Illnesses

Morabito and Socia’s (2015) study on this issue offers important new evidence about the role of mental illnesses in predicting subject or officer injury during police encounters that involve use of force, with an expectation that any real element of heightened dangerousness among persons with mental illnesses would translate to an increased likelihood of injury during those encounters in which force was used. They examined predictors of injury during these police encounters in Portland, Oregon—where all officers have Crisis Intervention Team (CIT) training—and aimed to determine whether subjects who were perceived by officers to be mentally ill were at an increased risk of injury for themselves or the responding officers. Notably, Morabito and Socia found no evidence that mental illnesses alone increased risk for injury in these cases but found that several other situational- and individual-level factors did, including assaultive behavior toward officer, resisting arrest, and being armed, as well as substance use, both alone and in combination with mental illness.

Morabito and Socia’s (2015) work makes an important contribution to what is known about real versus perceived dangers during police encounters with persons with mental illnesses. The absence of increased risk for injury among suspects with mental illnesses suggests that these individuals are not subject to disproportionately prejudicial and discriminatory treatment by police officers but rather that the situational circumstances and whether the suspect is intoxicated largely drive the intensity of police officers’ response. Furthermore, the absence of increased risk for injury among the responding officers in Morabito and Socia’s study suggests that any assumption by officers that mentally ill individuals are more dangerous to engage than others is unfounded. To the extent that these study findings can be generalized to other settings and police officers, it can help shape evidence-based approaches to policing practice.

Whereas Morabito and Socia (2015) set out to help answer the question of whether persons with mental illnesses are indeed more dangerous in their encounters with police than individuals without mental illnesses, their findings more narrowly reflect policing practices and outcomes among CIT-trained officers. All officers in their Portland, Oregon, study population were CIT trained at the time of the study, and so the results may not generalize to officers with no CIT training, who comprise most of the U.S. police force. The findings do, however, provide highly relevant data on a primary outcome of interest in the scope of CIT police work—the likelihood of injury to suspects with mental illnesses and to responding officers during encounters involving use of force. The absence of an elevated risk for injury associated with mental illnesses alone in this study cannot be attributed to a “CIT effect” given there was not a comparison group of officers without CIT training; nonetheless, it provides important preliminary evidence for more definitive research on the topic.

Another dimension of this study that would benefit from further investigation involves the severity of the subjects’ offenses surrounding these incidents. Controlling for offense-level characteristics could help illuminate the causal pathway to injury when encounters with police involve the use of force. Offense severity could confound the relationship between mental illnesses and injuries sustained during the encounter if (a) the subgroup with mental illnesses primarily interfaced with police for minor offenses (e.g., trespassing, loitering, and disturbing the peace) and was thereby at lower risk for more extreme use of force that leads to injury, and (b) the subgroup without mental illnesses primarily interfaced with police for more serious or violent offenses that might be more likely to lead to injury during police use of force. With that, accounting for severity of offense in the study design might reveal that persons with mental illnesses are indeed at higher risk for injury during police encounters involving the use of force if compared with persons without mental illnesses who committed a similar offense. Achieving a better understanding of the basis for injury during police encounters would add important clarity to this line of inquiry about police practice, officers’ presumptions about the dangerousness of mentally ill persons, and the extent to which those presumptions drive their course of action.

Mental Illnesses and Dangerousness: What We Know

A robust literature has explored the question of dangerousness among persons with mental illnesses, aiming to determine whether and how much more dangerous they might be than their counterparts in the community with no mental illnesses. National surveys have documented a widespread public belief that persons with serious mental illnesses such as schizophrenia are likely to be dangerous (Pescosolido, Monahan, Link, Stueve, and Kikuzawa, 1999); epidemiologic evidence paints a more complex picture. The NIMH Epidemiologic Catchment Area (ECA) Study found that 10% to 13% of adults with serious mental illnesses had committed an assault versus 3% of other adults in the community without mental illnesses (Swanson, 1994); more recent findings from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were consistent (VanDorn, Volavka, and Johnson, 2012).

The landmark MacArthur Violence Risk Assessment Study (MVRAS) (Monahan et al., 2001) found that 28% of a sample of discharged acute psychiatric inpatients—a relatively high-risk subset of all adults with mental illnesses—committed a serious violent act (i.e., causing injury to another person or using a weapon to harm or threaten another person). Interestingly, the results indicated that only those with co-occurring substance use disorders had an elevated risk, and those with mental illnesses alone were no more violent in the community than other residents of their same neighborhoods. The study sample, however, was situated in a high-risk neighborhood, so the risk for the subset with mental illnesses alone might have been elevated if compared with a more typical sample of the general population.

Estimates from the ECA study indicate that just 4% of violent acts can be attribute to mental illnesses, which means 96% of violence is committed for other reasons. In fact, persons with mental illnesses are far more likely to be victims of violence rather than perpetrators—with risks for victimization that are far higher than others in the general population (Teplin, McClelland, Abram, and Weiner, 2005).

Mental Illnesses and Dangerousness: A Broader Framework

Several studies following the MVRAS have uncovered important risk factors for violence among persons with mental illnesses that lie beyond their psychopathology and that are shared with offenders who are not mentally ill. Substance abuse is a leading predictor of criminal offending and violence in this population—as demonstrated also by Morabito and Socia (2015)—and has been well documented in several other community-based studies of adults with mental illnesses (Elbogen and Johnson, 2009; Robertson, Swanson, Frisman, Lin, and Swartz, 2014; Swanson et al., 2006, 2008; Van Dorn et al., 2012).

Other recent work has provided a theoretical framework and supporting empirical evidence todemonstrate the strong influence of factors beyond psychopathology among mentally ill offenders, including criminogenic and social-environmental risk factors. Along with substance abuse, Swanson and colleagues (2002, 2008) found that violent behavior in adults with mental illnesses was linked to a history of violent victimization and trauma, current exposure to violence in the community, and a history of longstanding antisocial behavior problems, typically beginning in childhood. Meanwhile, Gray et al. (2004) estimated that the actual risk for offending was largely attributable to criminogenic variables and found that the addition of clinical variables did not add explanatory power.

Skeem, Manchak, and Peterson (2011) devised an expanded framework for understanding offending in adults with mental illnesses, examining a broader range of direct and indirect influences on offending. Estimates in related work have indicated that mentally ill offenders are especially likely to have general risk factors for offending (Skeem, Winter, Kennealy, Louden, and Tatar, 2014)—including substance use—and that a mental illness itself is responsible for as little as 6% to 10% of offending (Junginger, Claypoole, Laygo, and Crisanti, 2006; Peterson, Skeem, Hart, Vidal, and Keith, 2010; Peterson, Skeem, Kennealy, and Bray, 2014).

A broad body of research has indicated that despite common perceptions among the general public, and possibly law enforcement, mental illness per se influences risks for offending and violence only modestly.

Next Steps for Research

Morabito and Socia (2015) have contributed an important new piece of evidence about outcomes of police encounters for persons with mental illnesses, indicating that they are no more likely than persons without mental illnesses to sustain injuries themselves or cause injuries to officers, which may be consistent with the literature that has demonstrated that mental illness alone does not substantially increase risk for violence. It could be that there truly is no elevated risk for injury among mentally ill individuals who interface with police and that the highly publicized incidents of officer-involved shootings of mentally ill persons are atypical. Morabito and Socia’s results also could indicate an unmeasured beneficial effect of CIT. Therefore, an important next step in this line of research would be a study that first compares rates of police use of force and then compares the rates of injury among subjects of police use of force in two groups: persons with mental illnesses and persons without mental illnesses, controlling for relevant officer-, subject-, and offense-level characteristispics.

It would be important to conduct this research in a jurisdiction that has both CIT and non-CIT officers, which would help determine whether the absence of elevated risk for injury for persons with mental illnesses in Morabito and Socia’s (2015) study was attributable to a beneficial CIT effect, given that all officers in their study jurisdiction were CIT trained. Identifying benefits of CIT in this context would both add to the literature on CIT effectiveness and help inform jurisdictions that do not yet have CIT programs during their considerations around its adoption and implementation.

A real contribution of a study like the one just proposed could be identifying differentialrates of police use of force among suspects with and without mental illnesses, along with differential rates of resulting injury in a representative sample of police officers, only some of whom have CIT training. It could be that, as Morabito and Socia (2015) found in their study, there are no differential rates of injury by observed mental status of the suspect, but that persons with mental illnesses are more likely to have force used against them. If mentally ill persons are indeed more vulnerable to police use of force, then it would be important to understand the extent to which the use of force itself has negative effects and not just the injuries that can result from it. Especially for individuals with mental illness, being subjected to police use of force could have both internalizing and externalizing harms—posttraumatic stress, a chilling effect if the experience were to engender distrust in police and other members of institutional authority, and reinforced stigma against persons with mental illnesses if community members observe these incidents and conclude that mentally ill individuals are dangerous and warrant that level of engagement by police as a necessary public safety measure.

Next Steps for Policy

During this time of national concern about excessive use of force by police, a range of stakeholders—including communities, federal and state governments, and law enforcement—seek improvements in community partnership, accountability, transparency, and skillful restraint to begin reversing the problems of excessive police use of force, including as they affect persons with mental illnesses. Prevention-oriented policies and programs that offer tools for improving de-escalation of potentially dangerous encounters with persons in a mental-health crisis could help minimize risk for injury during police encounters for all parties involved and reduce the likelihood that force will be needed at all. As an example, a recent trend in state law making broadens police authority to remove guns from persons who are considered to be in danger of harming themselves or others but who have not committed a criminal act and are not prohibited from gun ownership. Connecticut, Indiana, and California are three states with different versions of a law in place to remove guns from potentially dangerous persons. A benefit of this policy approach to managing potential dangerousness among persons in crisis is in removing the focus from mental illnesses per se and placing it instead on demonstrated behaviors by any member of the community that suggest heightened risk. This conceptual and operational shift in focus from mental illnesses to dangerousness is important for reducing stigma around mental illnesses, both in the community and among law enforcement officers.

There has also been increased awareness in law enforcement communities of the need for more in-depth officer training in de-escalation. The New York Times reported on a recent survey conducted by the Police Executive Research Forum (PERF) that highlighted the tradition of a disproportionate focus on training in use of force rather than de-escalation techniques and estimated the following median number of hours spent in various training areas: firearms = 58 hours, defensive tactics = 49 hours, de-escalation = 8 hours, and crisis intervention = 8 hours (Apuzzo, 2015). PERF asserted that some large police departments support the idea of a new approach to training that focuses more heavily on teaching officers the necessary skills to defuse tense situations and avoid violent confrontations; but other departments are resistant. Persons with mental illnesses would undoubtedly benefit during their encounters with police who had more comprehensive training in de-escalation and potentially reduce their chances not only of injury during those encounters but also of being subject to police use of force at all.

Certain jurisdictions have had strong success in implementing prevention-oriented models that include specialized officer response to persons with mental illnesses like CIT. Other successful additions to the community infrastructure provide officers with an alternative to taking a person in crisis to the emergency department or jail. San Antonio, Texas, paired CIT training with a newly constructed Restoration Center, a facility with a 16-bed psychiatric unit, a medical clinic, and a “sobering room” where police can drop off people who are intoxicated rather than taking them to jail. The city reports related savings for the police department of $600,000 a year in overtime pay alone; undoubtedly, many encounters that would have involved use offorce and possible injury were averted.

Morabito and Socia (2015) also call for policy improvements in consistency, quality, and availability of data on encounters during which police use force and the surrounding circumstances, including measures that thoroughly describe the circumstances of a person’s mental-health crisis. While a range of community and government stakeholders are engaged, now is an especially important time to develop and institute progressive policies in an effort to increase accountability for what takes place during police encounters. New policies that require detailed reporting of police use-of-force incidents would also facilitate further rigorous research on the effectiveness of CIT, preemptive gun seizure laws, and other approaches to mitigating dangerousness in encounters with persons in mental-health crisis. To ensure that new reporting policies are sustainable, however, jurisdictions would need to give careful consideration to issues around their implementation. Challenges to be addressed include the acceptability of such policies among police department leadership and their officers, as well as the feasibility of additional reporting and paperwork for officers and data management for administration.

Morabito and Socia (2015) offer salient new evidence about risk for injury during police encounters involving persons with mental illnesses in which force is used. Their study lays a foundation for further research that should extend to include non-CIT police officers to learn more about both CIT-specific outcomes and any unobserved elevated risk for injury during police encounters with persons with mental illnesses. Policy response to these concerns can begin now, starting with improved reporting on police encounters with persons with mental illnesses and a rigorous focus on building officers’ skills in de-escalation.