Recommendations for Implementation

Officers should approach and interact with people who may have mental illness with a calm, non-threatening manner, while also protecting the safety of all involved. Several de-escalation techniques (see Table 1) have been shown to assist in calming a person who is not rational or who is experiencing an emotional crisis.

Most people with mental illness are not violent, but for their own safety and the safety of others officers should be aware that some people with mental illness who are agitated and possibly deluded or paranoid may act erratically, sometimes violently. If the person is acting erratically, but not directly threatening any other person or him-or herself, such an individual should be given time to calm down.  Violent outbursts are usually of short duration.  It is better that the officer spend 15 or 20 minutes waiting and talking than to spend five minutes struggling to subdue the person.

The officer responding to the scene is not expected to diagnose any specific mental illness but is expected to recognize symptoms that may indicate that mental illness is a factor in the incident. Symptoms of different mental illnesses include, but are not limited to, those listed in Table 2. Many of these symptoms represent internal, emotional states that are not readily observable from outward appearances, though they may become noticeable in conversation with the individual.

In addition to the symptoms outlined in Table 2, some specific types of behavior may also be signs of mental illness.  These behaviors can include severe changes in behavior, unusual or bizarre mannerisms, hostility or distrust, one-sided conversations, confused or nonsensical verbal communication.  Officers may also notice inappropriate behavior, such as wearing layers of clothing in the summer. It should be noted that these behaviors can also be associated with cultural and personality differences, other medical conditions, drug or alcohol abuse, or reactions to very stressful situations.  As such, the presence of these behaviors should not be treated as conclusive proof of mental illness. They are provided only as a framework to aid those police officers who must understand what questions to ask and to decide what services, resources, or support are needed to resolve the cause of the incident.  Officers should obtain additional information at the scene from family, friends, or health professionals who are familiar with the individual's behavior.

Officers should be aware that substance abuse disorders can mimic many mental disorders;  substance use can mask many mental disorders; and some somatic disorders, such as diabetes or Parkinson's, may seem to be mental and/or substance abuse disorders.  To complicate matters, the co-occurrence of mental illness and substance abuse is also quite common (see Policy Statement 37: Co-occurring disorders). Due to the complexity of this diagnostic task,it will often be impossible for law enforcement officers to distinguish mental illness from substance abuse disorders. The officer who has observed unusual or erratic behavior should bring the individual to an assessment site that is capable of making an accurate determination of its cause.

Studies have shown that the potential for violence increases considerably when people with mental illnesses use alcohol or drugs.[1]  For this reason, officers should be observant and note any signs (e.g., bottles, drug paraphernalia) of substance or alcohol use. At the same time, maintenance of a calm demeanor and use of de-escalation techniques can help to prevent violent behavior.

Officers will need to attend to the medication needs of some individuals with mental illness.  If the encounter lasts for some time, or a person is being detained, people with mental illnesses may need access to their medication.  Officers must follow departmental rules for verifying that any pills or capsules the person is carrying are prescribed, or to obtain the needed medication, so that they may authorize the individual to continue the prescribed treatment.

Police officers should be aware that some medications that treat mental illnesses have side effects that may also require attention.  For example, medications may cause tremors, nausea, extreme lethargy, confusion, dry mouth, constipation, or diarrhea.  Police officers should attend to needs for water, food, and access to toilet facilities.  It is important not to mistake these side effects as evidence of alcohol or drug use.

No individual should be arrested for behavioral manifestations of mental illness that are not criminal in nature.  Arrest is generally appropriate when a felony has been committed or when the person has outstanding warrants. Arrest is also appropriate in cases in which the officer would normally make an arrest if the person did not have a mental illness, and if the current signs of mental illness are minor or not related to the violation.

In cases where the person with a mental illness has come to the attention of the police because of behaviors that result from the mental illness or nuisance violations, officers should engage referral mechanisms to mental health services and supports to address the mental illness in lieu of arresting the individual and engaging the criminal justice system.  (See Policy Statement 4: On-Scene Response, for more on referral mechanisms.)

On-scene expertise in mental illnesses and their manifestations is critical to effective incident management.  This expertise can be provided by primary or secondary on-scene responders who are specially trained police officers or mental health professionals.

The following examples highlight the ways that departments around the country have chosen to include this type of expertise.  As described previously, these include Crisis Intervention Teams (CITs), the comprehensive advanced approach, mental health professionals who corespond, and Mobile Crisis Teams (MCTs). The basic difference in these models is whether expertise is provided by police officers who are trained extensively in mental health issues, or by mental health professionals who either co-respond with law enforcement or respond after the scene has been secured.  While mental health professionals are likely more knowledgeable than patrol officers about involuntary commitment laws and bring additional, perhaps confidential, data to the scene, they are not always available. (See Policy Statement 25: Sharing Information for more on agreements between mental health and criminal justice agencies.)

Examples of approaches that use specially trained police officers to supply on-scene expertise - either as a special team or as the whole department - follow:

Example:  Memphis (TN) Police Department

In a Crisis Intervention Team (CIT) approach found in the Memphis Police Department, uniformed officers, specially trained in mental health issues, act as primary or secondary responders to every call involving people with mental illnesses. CIT officers are available on every shift and are also available to mental health clients (consumers) and their families. The Albuquerque, New Mexico, Police Department, The Roanoke, Virginia, Police Department and the Houston, Texas, Police Department are among numerous agencies across the country that have also adopted the CIT approach. 

Example:  Athens-Clarke County (GA) Police Department

In a comprehensive response, the Athens-Clarke County Police Department decided that its small size precluded the formation of a specialized team to respond to calls for service involving people with mental illness. Accordingly, the department decided that every officer would attend the advanced 40-hour crisis intervention training and thus be able to respond appropriately to these calls.

Example:  Birmingham (AL) Police Department

The Birmingham Police Department uses a Community Service Officer (CSO) Unit, which is attached to the Patrol Division. The unit is composed of social workers who respond directly to an incident location when requested by an officer.  They serve a variety of populations, including people with mental illness. The CSOs are also certified law enforcement academy trainers and work closely with community groups and other components of the criminal justice system.

Example:  Long Beach (CA) Mental Evaluation Team

In this program, a patrol officer from Long Beach Police Department is accompanied by a clinician to respond ten hours a day, seven days a week, to calls for service involving people with mental illness.  The clinician provides on-scene assessment of the individual's mental health needs and ensures admission into a mental health facility, if necessary.  This approach prevents unnecessary incarceration of people with mental illnesses.

Example:  San Diego County (CA) Sheriff's Office

The Psychiatric Emergency Response Team (PERT) approach used by the San Diego County Sheriff's Office pairs a licensed mental health clinician with an officer or deputy in a marked car to respond to situations determined by the dispatcher or another officer to involve a person suspected of having a mental illness that is a factor in the incident.  These teams conduct mental health assessments and process referrals to county providers if appropriate.

Example:  Anne Arundel County (MD) Police Department

The Anne Arundel County Police Department has arranged for access to a team of crisis workers from a local mental health center that works seven days a week. The responding officer must determine if a Mobile Crisis Team is warranted at the scene and will call accordingly.

There are several important differences between the approaches that involve mental health professionals. One main difference is how the mental health professional is paid and supervised, usually either through the police department or through the county mental health agency. For example, in Birmingham the social worker is located in the police department and is under the direct supervision of the chief, while in Anne Arundel County, Maryland, the mobile crisis team members are paid by a mental health organization. Another difference is whether the mental health agent works in a team with the officer, or responds as a separate unit. An additional distinction is whether the civilian workers respond to a variety of calls for service beyond those involving people with mental illnesses, such as domestic violence. Yet, in all models, the mental health professional is responsible for understanding community resources and finding services within the community.

Successful incident management is often dependent on information about the person's current and past behavior.  If it is not possible to obtain this information from the person with mental illness or a responding professional, sometimes it can be obtained at the scene from those who are close to the person, and who are familiar with the situation and with the person's history.

In those rare events when a person's life or the life of a bystander is in jeopardy, in addition to following standard crisis procedures, law enforcement should also formally call on specially trained mental health professionals for assistance in resolving the critical incident. (See Policy Statement 4: On-Scene Response, for more information on handling critical incidents.) Law enforcement personnel should protect the confidentiality of medical or mental health information to avoid disclosures (see Policy Statement 25: Sharing Information) and should follow protocols for written documentation provided in Policy Statement 5: Incident Documentation.

The criteria for emergency evaluation are similar from state to state, although there is some variation in how they are interpreted.  It is not the role of the police officer to make the sole determination that a person should be committed.  However, being familiar with the criteria will help officers decide whether to detain the person and transport him or her for an emergency mental evaluation.  This is not an arrest.  Officers should be alert to the behaviors, actions, and speech of the person so that they can determine whether specific indicators of the criteria apply.  Officers should also familiarize themselves with state law concerning emergency evaluation.

Most patients who receive inpatient or outpatient services for mental illness do so voluntarily. That is, when presented with their options - including the possibility of involuntary commitment - they choose to enter a hospital or to follow a course of outpatient treatment suggested by treatment professionals. In fact, in some states you cannot commit someone who is willing to admit him- or herself voluntarily. For a significant minority, however, there are times when involuntary commitment becomes the only available avenue to services and the surest way to ensure the safety of the person involved. Involuntary commitment involves deprivation of personal freedom and can be an indignity to the person being committed. In addition, it requires the participation of numerous professionals (including the certifying doctor, attorneys representing both the accepting facility and the patient, and a judge).  For these reasons and the simple reality that commitment takes considerable time, in the majority of cases most clinicians will seek to offer voluntary admission to services before considering involuntary commitment.

Every state has a law that provides a clear path for those cases in which a person must be involuntarily committed to treatment. While the laws vary to some degree, they all attempt to define circumstances under which a person's unsupervised presence in the community poses a risk by reason of his or her mental illness. In almost all cases, it is the likelihood of a person's dangerousness to self or to others that is the primary trigger for involuntary commitment. In several states, the mental health law also includes language defining what is broadly known as the "gravely disabled" criterion, which is meant to cover instances in which a person's well-being is threatened by inattention to personal safety, failure to eat, exposure to extreme or dangerous conditions, or other evidence that he or she is in imminent danger if left untreated. Some state statutes also note a "need for treatment" or likelihood that a person will benefit from treatment as one of many criteria for commitment. Additionally, the laws covering involuntary commitment are subject to interpretation and, it should be noted, continued debate within the mental health community.

Traditionally, the treatment to which a person is involuntarily committed is provided in a secure inpatient facility. State law generally charges the department of mental health or its equivalent with regulating facilities to which involuntary commitment is possible. Not all hospitals are licensed to receive involuntary patients (although this does not always restrict their ability to conduct emergency evaluations). In addition, reimbursement issues may limit admission to some hospitals.  It is important for law enforcement officers and others who might become involved in involuntary commitment proceedings to know which facilities are able to admit involuntary patients.

In some states, involuntary commitment to outpatient services is also possible under the law. As with involuntary inpatient commitment, there is considerable controversy within the mental health community with regard to the acceptable purposes and uses of this option. There is also considerable variability in the manner in which outpatient commitment is utilized. Not only do states have different standards in the law, but judges and doctors can and do differ widely in their understanding and use of discretion regarding the appropriateness of invoking outpatient commitment provisions.

To avoid the adversarial dynamics of involuntary commitment, in some instances crisis teams may consider the use of alternative dispute resolution (ADR). Crisis teams should consider including personnel trained in ADR techniques who can attempt to resolve conflicts short of involuntary intervention.

Many people with mental illness today have some broad understanding of involuntary commitment laws and of the rights they have under those laws. More broadly, many who have been in treatment have learned to understand their illness, to monitor their symptoms, and, ideally, to manage their condition. Patient education is a significant component of treatment in some mental health agencies. Some consumers have arranged to provide information to emergency responders (e.g., through wallet cards) on whom to contact in the event of a crisis. Officers should be aware that someone with a mental illness who is expressing a preference for particular actions, medications, or modes of treatment may be speaking from experience. The person's requests should be relayed to any treatment professional called to the scene or consulted in follow-up to an incident.

"Advance directives" are legal mechanisms by which a patient's preference for particular medications or treatment alternatives can be expressed prior to a crisis, much as many in the general population execute "living wills" or other legal documents outlining their wishes should medical crises leave them unable to express themselves in this way. Officers should be familiar with this mechanism and should be aware of the possibility that a person with mental illness may wish to follow the steps outlined in his or her advance directive. In cases where the advance directive is followed, the person with mental illness may more readily agree to become engaged in services, thereby eliminating the need for involuntary commitment.