(Editor’s note: this is the second in a series about restructuring mental health services.)
(7-3-20) The defund the police movement has sparked conversations about shifting responsibility for the seriously mentally ill away from law enforcement back where it belongs – on social services and the medical community.
This is a great opportunity for improving mental health care, but we must be realistic and answer some tough questions.
We cannot fully end all interactions between the police and courts with the seriously mentally ill. Americans with untreated serious mental illnesses can be dangerous. Involuntary commitment hearings are legal matters. I find talk about arming social workers or completely dismantling police departments counter productive. Our goal should be to create a mental health system that doesn’t rely on the police as first responders and minimizes court involvement.
Step One: If money is to be shifted from the police department budgets to mental health services, those funds should be spent directly on programs that will help reduce arrests, shootings and incarceration. While admirable, it is difficult to see how early education programs in schools about mental illnesses and community youth programs will reduce police engagement. Greater access to integrated health care, peer support, housing, Assertive Community Treatment teams, mobile crisis response teams, crisis care beds, adequately staffed drop off centers that are warm and welcoming – these are where siphoned funds should be spent.
Training Will Not Fix The Problem: I’ve always been a strong and vocal supporter of Crisis Intervention Team Training. CIT trained officers are heroic and what all police officers should aspire to be –compassionate problem solvers. No one wants RAMBO answering a mental health call. But we cannot train our way out of our mental health crisis and we can’t depend on the police to fix our patchwork system.
The Washington Post, recently noted that “a 2014 Criminal Justice Policy Review meta-analysis showed no improvement in safety for officers or the public from the use of crisis intervention teams. A 2019 study by researchers at the University of California at San Francisco and San Quentin State Prison found that evidence to support the training was contradictory and that in most cases, deploying the teams didn’t affect arrest and use-of-force rates. The only time we see improvement in the outcomes of these calls is when such teams are combined with increases in community-based mental health services.”
Involuntary Commitment: If we want to reduce police involvement, we need to find a better standard than waiting for someone to become a danger to themselves or others before we intervene. I believe our current reliance on the dangerousness civil commitment criteria promotes arrests, incarceration and violence. Australia is considered a world leader in mental health care. We should follow its “need for treatment” lead.
As part of this shift away from dangerous, we need to develop a system that provides help and services before involuntary commitment becomes necessary. During a recent PBS radio show, a Bexar County, Texas official noted that more than 1,200 individuals were involuntarily committed each month in the San Antonio area. Nearly all of them were held for three days, given medication and then returned to the same environments where they experienced a crisis. The result: “a revolving door” with few getting better. What does this accomplish besides fear and resentment?
Establishing a “need for treatment” civil commitment standard requires actually providing treatment.
Inpatient Care: We must accept the fact that some seriously mentally ill individuals need inpatient treatment for longer than a few days or weeks. Serious mental illnesses are difficult to treat. There has been much talk about bringing back state hospitals. The truth is that we have never shut down longer term treatment facilities. We simply have made them only available to individuals who can afford the high costs of such excellent facilities as McLean Hospital or such healing communities as Gould Farm or Cooper Riis. I know of an individual who spent two years at McLean Hospital before the symptoms of his schizophrenia were stable enough for him to return to his home, find work and marry. Because of past abuses, we rightly fear a return to state hospitals – and we should. But a major reason those state hospitals turned into abusive warehouses where individuals were dumped is because the hospitals were never adequately funded. Talk about reducing police involvement should include serious discussions about increasing community based crisis care bed capacity and access to longer humane care on the level of a McLean Hospital, not a snake pit. That will take money and an attitudinal change .
Humility: If we want to reduce police involvement, we need to recognize our own limitations. While our goal is – and should be – for everyone to get better in our communities, some will not. The Rule of Three, which has been widely accepted in mental health, states that one third of individuals with a serious mental illness such as schizophrenia or bipolar will recover completely, one third will show improvement, and one third will not get any better. We must realize that we might not have the medical knowledge to help the seriously mentally ill with their symptoms. This doesn’t mean we abandon them to the streets and our jails. Robust programs such as Housing First, Assertive Community Treatment Teams, and other interventions should be available so that someone who is sick can be cared for in our communities even if they continue having symptoms. Those who are the most sick need a social connection with someone who cares about them.
An “Aspirational” approach
Let’s admit it. We currently do not have a comprehensive mental health care system in America. What we have is a patchwork of programs, most of which, are designed to respond to crises and then apply a band aid. We wait for someone to hit rock bottom before offering help because of limited community resources and access to doctors, therapists, social workers and peers.
It doesn’t have to be this way.
In an opinion piece that I wrote last month for The Washington Post, I described an Air Traffic Controller approach. Mental health calls would be directed to a separate telephone number – not 9-1-1 – for suicide and mental health emergencies. Trained mental health counselors would triage calls, offering to schedule an appointment with an available pool of psychiatrist or counselor if needed. If something more immediate was required. dispatchers could send a mobile crisis response team. Only as a last resort, would law enforcement be called.
Rather than delivering individuals in crisis to a jail or emergency room, they would be taken to a drop off center that was welcoming, non-threatening and staffed by peers, as well as, other mental health professionals. The centers would be equipped with crisis care beds. If necessary, individuals could be directed to longer term inpatient beds. Regardless, housing, Assertive Community Treatment Teams, job help – whatever services would be needed would be offered.
How realistic is such a system?
Not very right now. But talk about shifting responsibility for the seriously mentally ill away from the police offers us an opportunity to take steps toward creating a better system.
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