Mental health and policing: Picking up the pieces in a broken system

The mental health service system is a series of silos

When Sam (note 1) was taken to hospital via police car after being apprehended under the British Columbia (BC) Mental Health Act, the last thing she expected was to be released from the hospital without any kind of treatment or referrals to community-based supports. ^1,2 The 29-year-old had been dealing with depression and anxiety for years, and it had come to a head. After her second and third hospital admission within 6 weeks, she was again discharged without anywhere to go. People who are living with serious mental illness—people like Sam who has an estimated 400 contacts with police since 2012—often cycle through the “system” for years and come into contact with police and other emergency services—for low-level, misdemeanor crimes or non-emergent concerns—and many of these people have contact with not only the jail but also homelessness and emergency medical services. ³ Unfortunately, Sam and those in similar circumstances have one of the lowest life expectancy rates in the country, typically living between 10 and 32 fewer years than the general population. ^{3 –5} Despite awareness campaigns, funding measures, and generally good efforts to fight the stigma of mental illness, this life expectancy gap has not changed in 30 years. ^{6 –8}

A key theme of this article is the need to view the intersection of public safety and public health through a new lens to break down the traditional information silos of the many agencies that serve vulnerable populations and the impact of insufficient community-based mental health services that contribute to the rise in the number of calls to police to respond to people in or approaching mental health crisis. ^{3,9 –12} These contacts have increased in recent years due to a variety of factors, including displacement from institutional settings without adequate increases to community support. ^{13 –17} Unfortunately, community support systems have not received sufficient funding or policy support to meet the growing demand for mental health services. ^{10,18 –20} The result is the increased prominence of the police as part of the mental health system, particularly in times of individual crisis. ^{1,5,9,11,14,16} There is substantial research that suggests that the system needs a reset from reacting to immediate health and crime events as distinct events to focusing on holistic approaches that result in better individual outcomes, increased public safety, and reduced police involvement. ^{3,4,6 –8,11,13 –25}

For the last 40 years, BC has pursued a general policy of deinstitutionalization, moving to a variety of alternative community-based strategies, including crisis intervention and response models for people living with mental illness. While noble in intent, the execution of the policy has been a failed experiment. There appears to be good evidence that governments have not adequately resourced mental health supports in this environment of deinstitutionalization. ^{5 –7,11,18,19,22,25 –27}

The “mental health system is broken” is a phrase used regularly to describe the current mental health service delivery system. In fact, the use of the term mental healthcare delivery system (ie, points of access in crisis, primary and specialty care, community supports, family and caregiver support, housing, financial aid, patient rights, and more) suggests order, integration, and accountability that do not currently exist. ^28,29 Communication, collaboration, cooperation, and systems planning among the various entities who make up the service delivery continuum are limited and almost incidental to their operations. ^7,30,31 A lack of capacity in the mental health system is failing persons in or approaching crisis as a result of mental illness. ³² The gaps are often filled by local police resources, resulting in diversion away from traditional policing duties. People experiencing homelessness, vulnerable population groups, people living with complex health issues, Indigenous people, and youth are most impacted by the “broken” mental health system. ^{10,33 –36}

While the “system” is broken, the modern trend towards the deinstitutionalization of People With Mental Illness (note 2) (PwMI) and the model principle that patients should have the freedom to decline mental healthcare except in extreme cases mean that a substantial number of people in crisis face encounters with police. In turn, the police may lack sufficient awareness of existing supportive resources, as this information is not comprehensively organized and accessible. ^{37 –40}

Although resources are available in most Canadian cities, and despite the efforts of the people who work to deliver mental health services to PwMI, the existing “system” is one in which people often get lost. ^{10,13 –15,17,20,24} It needs to be said that BC, like other jurisdictions, would benefit from a systematically coordinated and better-funded mental health system linked to community-wide targeted outcomes for PwMI. ^{2,5,6,8,21,31,36,41}

This suggestion is not intended to reflect poorly upon the people now working in mental healthcare in BC. Instead, it is a comment on the overall funding and coordination of mental healthcare in the province, which, at present, does not function as a comprehensive shared team-based system of care.

It is important to recognize that mental illness is not, in and of itself, a police problem. However, actual or perceived behaviours associated with PwMI often lead to community concern for safety resulting in calls to police, usually the only accessible 24-hour service available. Law enforcement personnel are routinely the first line of response for situations involving mentally ill people in crisis, and as a result, officers may have assumed the role of “street corner psychiatrists” by default. ^{13 –16,31,35,42} Neither the mental health system nor the police and justice system can manage mental health crises in the community effectively without collaboratively working together to fix this “broken system.” ^33,39

People with mental illness and contact with police

According to a Statistics Canada survey, ^12,20 one in five Canadians who are 15 years of age and older reported contact with police within the 12 months preceding the survey, and 18.8% (940,000) of that population had either a mental illness or a substance use disorder. ⁹ Moreover, evidence suggests the following:

two in five PwMI have been arrested in their lifetime,

It is estimated that over 20% of police time is spent responding to PwMI. ^{13 –16,34,35,38,43,44} In some circumstances, this may be necessary and unavoidable as the police are often the first point of call for people in distress, crisis, and emergency. Yet, in cases where a person has committed no offence and is principally in need of medical intervention or the support of health and social care services, it is typically not the preference of the person in distress to engage with police officers nor is it in the interest of the police or the public to take police officers away from their core public safety focused frontline duties to deal with these situations. ^28,29,45,46

While most people in crisis may only have a single encounter with police, an increasing number with mental illness and/or substance use disorder have repeat encounters. ^3,46,47 Those who have repetitive and frequent contacts with police due to their mental illness are of growing concern to communities, police, policy-makers, and researchers globally. Commonly referred to as super utilizers (note 3) in law enforcement circles, ^{3,13,14,46 –48} these individuals often cycle between hospital emergency rooms, jail, shelters, transition housing, regional correctional centres, to the streets and back again. ^3,15,24,31 Super utilizers are thought to be a relatively small subset of the broader population group who have contact with the police but represent a significant influence on community emergency services as a whole. ^{1,4,6,9,10,24} They may be more likely to be homeless and have dual diagnoses of mental health and substance use disorders. ^{3,10,11,13,17,23,24,49} Encountering these same people again and again overburdens law enforcement agencies, strains limited resources, and can be frustrating and demoralizing for officers who are unable to help the individual. ^3,27,50

People with repeat encounters with police are a priority for various reasons. ^10,47 The elevated risk of criminal victimization associated with mental illness increases the rate of police contacts with PwMI. ^18,45 Increasingly, the police have assumed an expanded role of maintaining social order and responding to individuals experiencing mental health crises. ^43,45,47 The police have also become the principal first responders to situations involving PwMI, which has earned them the title of “psychiatrists in blue.” ^4,6,8,13,14 The role of policing PwMI has been controversial for many years, and more recently, as a result of the Black Lives Matter movement, there is a notion that not only should this role not exist but that the presence of the police in the mental health system is proof positive that the system is “broken.” ^{19,22,23,26,31}

The current system highlights how the onus is often placed on police to attend to the needs of a person in crisis, connect them to the appropriate mental health services, and resolve conflicts in community settings in a peaceful manner. The police ability to do so is complicated within the context of a highly complex, fragmented, and uncoordinated service delivery system.

Identifying mentally ill “super utilizers” as a first step to reducing police contact

The failure of our mental health service delivery system is a national crisis with impacts felt far beyond those experiencing homelessness and/or living with severe mental illness. When vulnerable citizens are living without shelter, experiencing crisis, and unable to access care, they frequently end up in systems that were not designed for frontline mental healthcare. ^{12,24,34,35,39}

The number of times police are asked to apprehend and detain someone under the Mental Health Act (MHA) has risen by an estimated 20% over the past 5 years. ^10,42 Better support is needed to avoid the “revolving door” wherein the same people are repeatedly detained and released. ³ The care they receive is fragmented and uncoordinated and comes at great cost to the system on all levels. ¹⁰ This often results in poor outcomes for many of the people living in shelters, transition housing, single room hotels, and tents/encampments, all of which are not “safe places” for PwMI when discharged from hospital. ⁵¹ This is especially true for individuals who require medication management or community-based home care services. ^39,44,52

To design an effective strategy, the first step is to understand the complete picture of people who have frequent contact with police, including where and how officers are coming into contact with them, will help the police, and community agencies more effectively allocate their limited resources to match the scale and needs of this population. ⁴⁶ Identifying and understanding the high utilizers in the community can aid policy-makers as they work to reduce time-consuming interactions. The initial contacts are rarely criminal in nature but usually result in an apprehension and arrest because a person is believed to be a danger to themselves or others due to a suspected mental illness. ^{27,32,41,53,54}

Strategically, by identifying this population, collaboratively, communities can ensure policies and procedures are clearly written and articulate the roles and responsibilities of officers and partners to effectively respond to people who are high utilizers and connect them to appropriate services. ^{3,4,6,8 –10,13,15,16,42} They should also outline ways for officers to communicate and legally share information, with mental health and social service professionals to ensure appropriate and helpful connections to care and provide guidance on what to do during an encounter. ^3,36 Moreover, identifying the nature and scale of demand is key to understanding the pressures that responding to repeat call demand, places on our already lean police resources. ⁵⁵

Police and mental illness: Joining up services

Many communities have recognized the need to improve the response to a PwMI crisis by utilizing appropriate linkages to community-based care to reduce emergency department visits, hospitalizations, and arrests. In most cases, programs were developed through collaboration between police, mental health service providers, and others invested in addressing the issues. ^{30,49,50,56,57} The range of programs highlighted in the literature review include the following:

mobile teams of police and mental health professionals to respond to mental health crisis;

The evidence suggests that each of these approaches has promise for meeting the goals of improving police responses to crisis situations; however, it does not address the continuum of service needs for PwMI from a perspective of prevention. As previously stated, super utilizers have repeat mental health crisis calls (some as many as 150 per year) and require an integrated response that cuts across a “system” of partners including government, health and social services, and organizations such as the police. ^3,17,32,49

By using the super utilizer identification method to prioritize those in the community with the highest need, the wider community of mental health professionals and police can collaboratively determine what approaches are most promising for ensuring future mental health and minimize the need for police. ^{3,13,33,37,39,46,47,58}

Previous articles described fragmentation and silo services, and it has been suggested that more research was required given the lack of evidence for certain models. ^30,36,49,50 For example, there is a significant need for research and systems analysis on integrating physical and mental healthcare, especially involving case management models for this population group. ^{3,30,46,47,50} The further research should examine service model implementation, intended outcomes, alignment and fit to community expectations, information system adequacy, and cost-effectiveness. ^{3,4,7,20,59 –61}

Much pressure has been placed on police organizations to improve the approach to community mental health. The responsibility for implementing a prevention/recovery model to improve health outcomes for PwMI cannot rest with the police alone—all levels of government, health authorities, social service agencies, not-for-profit agencies, foundations, and the community sector are essential partners. A population health approach is necessary to address the full range of factors that influence the system for the health and well-being of PwMI including the wider social determinants of health. ⁶²

A generic “off-the-shelf” approach to implementing mental health crisis management solutions will not work. A local, place-based approach is necessary, recognizing that vulnerable populations are not static and that geographical boundaries shape access and entitlement to services. The success of these responses embeds silo commitment to appropriate and sustainable funding for resources (people, vehicles, and information system). ⁶³

Our world has become no less surprising in the year since the publication of previous articles that suggested new approaches for combating healthcare system fragmentation and silo services. ^{10,36,52,54,64,65} Utilizing a population health and simulation approach at the community level will help all participants responsible for funding service outcomes to understand the demand for future resources, services, case mix, outcomes, and ongoing costs—leading to care models designed to address the needs of vulnerable people. ^{3,30,54,61,62,64,65,66}

What is next? Building a mental health service system for PwMI

Few would argue that transport in the back of a police car is the best approach to get people in crisis to care. 911 call-takers, dispatchers, and police officers can benefit from improved training to recognize symptoms of mental illness and have the capacity to immediately transfer and/or refer to mental health services instead of to an emergency department where those services exist. Additionally, PwMI must have adequate and appropriate support in the community in terms of housing that is “more” than a bed. ⁶¹ Housing, food security, and activities that reduce isolation and social exclusion are critical if the community is serious about shifting from a crisis system to a system of prevention and recovery that reduces 911 mental health crisis calls and improves community safety. ⁶⁷

The seven steps listed below, based on the synthesis of the jurisdictional literature and the authors’ previous studies, provide an action guide to fixing the “broken” service delivery system and reducing police interactions with PwMI. The seven steps include:

Building stronger linkages between the police and the primary care and mental health community by embedding partnership year-on-year accountability agreements that clearly define roles, responsibilities, outcomes, and performance targets.

Building an effective system for PwMI takes long-term commitment. Governments on all levels must step up and agree that mental health is a social responsibility and move to providing barrier-free access to integrated physical and mental healthcare. Moving to action achieves a provincial primary target of the BC government—attaching every citizen to a primary care physician.

Conclusion

The evidence supports that health services are under significant strain, particularly in crisis care. Several decades of studies have warned of a national mental health crisis. The manifestation of this crisis in community is that the police are too often the first port in the storm. Until mental health is given the same priority as physical health in resources and funding, PwMI will not be adequately serviced and the police will continue to play too large a role. As highlighted in the literature, members of the public do not have an obvious resource to turn to when they see somebody behaving in a concerning way, so people tend to dial 911 for the police.

The system needs fixing. Joint triage schemes between health, social services, and the police have been positively reviewed by many working within the system. Perhaps the most important element has been the overarching spirit of collaboration between mental health agencies and law enforcement in developing policies to address their community issues. There is, however, an immediate need to better identify and understand the specific needs of individual communities to align future demand for funding, partnerships, resources, and accountability, including outcomes from these joint approaches alongside data sharing. The health service has an aspiration to move towards better crisis care, but the funding and activation happens slowly. An ounce of care is more expensive and has poorer outcomes than a move to a pound of prevention.

Mental health and wellness must be viewed as an important part of the public healthcare system. Police are governed by the Peel principles of good policing and dedicated to public safety, particularly regarding the prevention of criminal behaviour, but police also become involved in individual safety—especially when the behaviours of PwMI may be seen to threaten other citizens or the individual themselves. ⁶⁸ This is where the role of police and mental health specialists may coincide with effective handovers to an integrated health and social care system rather than to the justice system.