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Journal of Police Crisis Negotiations, 10:30–38, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-2586 print / 1533-2594 online
DOI: 10.1080/15332581003757297
A Strategic Approach to Police Interactions
Involving Persons with Mental Illness
GLENN S. LIPSON, JAMES T. TURNER, and RANDY KASPER
Alliant International University, San Diego, California, USA
A growing challenge for law enforcement is dealing appropriately
and effectively with persons with mental illness. Individuals expe-
riencing acute symptoms of mental illness may respond differently
than what front-line officers expect. Thus, persons with mental ill-
ness raise risk issues regarding intervention, strategy, and program
framing. As the population grows and ages, so does the number
of persons with mental illnesses. First, we look at the prevalence
of mental illness. Second, the evolving research on the relationship
between violence and mental illness is presented. Third, we discuss
how individuals with mental illnesses are also at risk of being vic-
timized by crime. Fourth, we examine what additional risk factors
police can explore to determine the threat level posed when respond-
ing to a person with mental illness. A specific technique that officers
can employ to more effectively gather information, reduce the risk
of confrontation, and promote cooperation is used as an example.
KEYWORDS Police, mental illness, risk factors, strategic ap-
proaches
The National Institute of Mental Health estimates that about 1 in 4 adults will
suffer from a diagnosable mental illness during any given year. When ap-
plied to the 2004 census data, that translates into approximately 57.7 million
people (National Institute of Mental Health [NIMH], n.d.). Approximately 6%
of the population, or 1 in 17, have what is considered serious mental illness,
defined as schizophrenia, bipolar disorder, obsessive-compulsive disorder,
major depressive disorder, panic disorder, schizoaffective disorder, and delu-
sional disorder (NIMH, n.d.). About half of those with mental illness suffer
Address correspondence to Glenn S. Lipson, California School of Forensic Studies, Alliant
International University, 10455 Pomerado Road, Room B-1, San Diego, CA 92131. E-mail:
glipson@alliant.edu
30
A Strategic Approach to Police Interactions 31
from more than one mental health disorder, meeting criteria for two or more
diagnosable disorders (NIMH, n.d.). Mental disorders have a profound indi-
vidual and societal impact. They are the leading cause of worker disability
claims for persons aged 15 to 44 in the United States and Canada.
Following our recent actions in both Iraq and Afghanistan, police will be
required to deal with a population of veterans with mental illness who may
also suffer from head injuries, permanent physical disabilities, and posttrau-
matic stress disorders. For these individuals, bizarre behavior can be triggered
by sounds, flashes, or appearances that remind them of memories related to
exposure to death and trauma in combat. As in previous generations, many
of the homeless will be veterans. This creates additional challenges for police
in terms of the need to manage individuals with military experience, mental
illness, and who may be homeless and/or chronically unemployed.
Additional challenges also arise from the aging of the population in the
United States. As an increasing number of individuals suffer from forms of
dementia resulting from Alzheimer’s disease (AD) and other disorders, the
number of police calls to intervene will increase. The National Institute of
Aging suggests that there are 2.4 to 4.5 million Americans that suffer from
AD. Since the incidence of this disease increases with the number of aged
in the population, the problem will grow. In 2030 there will be 72 million
people older than 65 in the United States (U.S. National Institutes of Health,
2010). The effect will result in officers’ dealing with considerably more cases
of both domestic and civil disputes involving the aged.
THE RELATIONSHIP BETWEEN VIOLENCE AND MENTAL ILLNESS
Evolving research is leading to a better understanding of the complex rela-
tionship between violence and mental illness. In general, it is falsely assumed
by the public that persons with mental illness are more likely than the “norm”
to be dangerous. The research in this area is still full of contradictory find-
ings based on the different populations studied, definitions of violence, and
more. This leads to confusion for the public and for police officers.
An association between psychosis and violence was found in a recent
meta-analysis, but the effect size was small (Douglas, Guy, & Hart, 2009).
The implication is that most violent individuals are not psychotic and that
most psychotic individuals are not violent (Douglas et al., 2009). Police offi-
cers typically respond to low-level misdemeanor offenses and nuisance calls
with individuals who have mental illnesses rather than to violent incidents
(Vickers, 2000).
Externalizing disorders such as substance-abuse disorders, antisocial
personality disorder, psychopathy, or early-onset criminal behavior are more
predictive of violence than psychosis. Persons with psychosis are more likely
to be violent than those with internalizing disorders such as nonpsychotic
32 G. S. Lipson et al.
mood disorders or healthy persons in the general population (Douglas et al.,
2009).
Nonetheless, persons with mental illness are often depicted in the media
as aggressive individuals who are violent, dangerous, and unpredictable. For
example, many of the villains in the Batman comic books, video games, and
film series are sentenced to the Arkham Asylum, a facility for the criminally
insane. This reinforces the perception that persons with mental illnesses
are a dangerous bunch. Police officers, like the general public, also hold the
illusionary belief that the risk of violence is much higher when mental illness
is present (Monahan & Steadman, 1994; Monahan et al., 2001). Ruiz and
Miller (2004), for example, found that approximately 43% of police officers
surveyed strongly agree that persons with mental illness are dangerous.
Research demonstrates that while mental health calls may only be a small
fraction of police work, they tend to be both time consuming and complex to
handle (Borum, Deane, Steadman, & Morrissey, 1998; Reuland, Schwarzfeld,
& Draper, 2009). It is not uncommon for officers to repeatedly respond to
the same locations, creating both a drain on resources and an increase in
frustration for those answering the calls. Officers take approximately 30% of
the persons with mental illness they encounter into custody (Schwarzfeld,
Reuland, & Plotkin, 2008). They might be transported to an emergency room,
a jail, or a mental health facility. These encounters can have significant
consequences for all the parties involved. Front-line officers are left with the
need to stabilize these situations and determine whether the person poses a
danger to themselves or others. The concern that persons with mental illness
are violent reinforces the view of their potential lethality and can result in
the use of unnecessary force (Ruiz & Miller, 2004). This concern should be
covered in police training because individuals with mental illness are four
times more likely to be killed by the police (Cordner, 2006). Some of these
incidents may be an individual’s attempt to commit suicide by being shot by
someone other than themselves, commonly known as “suicide by cop” (SbC).
Other incidents involve an escalation of noncontained and seemingly bizarre
behavior, which can escalate into violence. When an individual cannot make
eye contact, is screaming, is not making sense, or seems irrational, people,
including police officers, tend to become more fearful.
MENTAL ILLNESS AND CRIME VICTIMIZATION
The violence and mental illness link emphasizes the risk that persons with
severe mental illness pose to others. However, lost in this mix is violence
directed toward persons with mental illnesses. A review of nine studies and
5,195 patients revealed rates of victimization among persons with mental
illness as being anywhere from 2.3 to 140.4 times higher than the general
populations (Maniglio, 2008). Persons with severe mental illness are at a
A Strategic Approach to Police Interactions 33
higher risk in part because of their deficits in social skills, planning, problem
solving, reality testing, and judgment (Marley & Buila, 2001). Other factors
include living in disadvantaged neighborhoods and unsafe housing. These
deficits can result in poor decisions that place them at risk. Violent crime
victims suffer from both physical and mental injuries, diminished quality of
life, higher rates of suicide, and reactive drug and alcohol abuse (Maniglio,
2008). Patients who suffer from disorders within the schizophrenia spectrum
in particular are at an increased risk of victimization (Fitzgerald et al., 2005).
MENTAL ILLNESS AND LESSONS FROM THE PRISON POPULATION
Studies of incarcerated individuals with mental illness shed light on the char-
acteristics and background of offenders with mental illness. The offender
with mental illness often has had a troubled life. Inmates with mental ill-
ness are three times more likely to have been both physically and sexually
abused as children when compared to inmates who do not have a mental
health diagnosis. Of those in state prisons, 18% of those with mental illness
have lived in a foster home, an agency, or other institution during childhood
(James & Glaze, 2006). This data gathered by James and Glaze (2006) re-
lied on a broad definition of mental illness. Either symptoms or treatment
must have occurred in the preceding 12 months prior to being interviewed.
A mental health problem was defined in reference to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition,(DSM-IV-TR; Ameri-
can Psychiatric Association, 2000) and if the person received treatment from
a mental health professional. Thus many minor and less-severe diagnoses
were defined as mental illness in this study. With this caveat in mind, they
found a third of those incarcerated in federal facilities reported they had
a parent or guardian who abused drugs or alcohol during the incarcerated
person’s childhood or adolescence. Half of those with mental illness had a
family member who was incarcerated while growing up. These experiences
impact the ability to form healthy attachments and are related to an increase
in substance abuse (Flores, 2006).
Looking again at state prisoners, those persons with mental illness were
twice as likely as other inmates to have been homeless a year before their
arrest (James & Glaze, 2006). In percentages, 13% of those with mental
illness in jails were homeless before they committed the offense that resulted
in their incarceration. Approximately half of the inmates in jail had mental
health problems, according to the Bureau of Justice Statistics (James & Glaze,
2006). This data was gathered from personal interviews with state and federal
prisoners in 2004 and local jail inmates in 2002. The estimates were that 45%
of the federal inmates, 56% of state inmates, and 64% of jail inmates had
mental health problems. In state prisons 73% of females had a mental illness
compared to 55% of the males.
34 G. S. Lipson et al.
Incarceration can place persons with mental illness at risk. This occurs in
part because inmates who have mental illnesses may engage in behaviors that
other inmates find irritating, behaviors that do not conform to inmate culture,
or behaviors that increase their vulnerability. State prisoners with mental
illness are twice as likely to be assaulted after admission to general housing
units (James & Glaze, 2006). Inmates with mental illness often require special
segregation, repeated observation, and suicide watch.
RISK FACTORS
Since severe mental illness is associated both with aggression and victim-
ization (Hodgins, Alderton, Cree, Aboud, & Mak, 2007; Teplin, McClelland,
Abram, & Weiner, 2005), the presence of contributing conditions are an
important factors in evaluating the risk level of an interaction. Positive symp-
toms of psychosis (hallucinations, psychotic actions, delusions, and paranoia)
increase risk of violence. Symptoms of disorganization, if present, are also
related to violence. Secondly, the presence of active substance abuse in a
specific interaction with mental illness raises the risk of violence substantially.
At least half of the persons with major mental illness have a co-occurring
substance abuse. Thirdly, a history of prior violence increases the assess-
ment of potential risk. A fourth factor that police officers need to consider
in evaluating the risk of violence is the presence of dementia, especially if
associated with a history of psychopathy.
INTERVIEW TECHNIQUES WITH PERSONS WITH MENTAL ILLNESS
Most of the difficulties with providing interventions for persons with mental
illnesses are related to system design issues. By “system design issues” we
are referring to the lack of programs, psychiatrists, and inpatient beds to
keep those with mental illness off the streets or maintained supportively as
outpatients. The challenge remains for officers to assess and intervene when
required. Officers may be called on to intervene with a person who presents
with delusional thinking or unusual beliefs. “Suspended disbelief” may be
an effective method to address each situation. Suspended disbelief means
one communicates to the parties involved that you understand they have a
belief that is justifying their actions. You have not had their experience. You
wish for them to share what has happened to them. You communicate that
you are skeptical by nature but will listen to them because in life sometimes
the improbable happens. You also inform them that you want to obtain your
own information to corroborate what they are reporting.
This position of suspended disbelief is different than confronting some-
one, ridiculing, or ignoring their statements. Often if individuals are given an
A Strategic Approach to Police Interactions 35
opportunity to share their delusion, to “feel heard,” the situation will more
easily de-escalate.
In these circumstances, rather than acting exclusively as a limit or bound-
ary setter, the law-enforcement officer is acting more like a container. The
person expresses the source of their agitation, and the officer involved lis-
tens. Depending on the particular elements of the situation, responding to
their belligerence, confusion, and disorientation by the immediate use of
force may escalate events. To respond with calmness, directness, and that
type of containment as a listener with suspended disbelief, helps to de-
escalate situations. In these situations, the voice is softer and more soothing
than a standard command tone. Of course anyone in the field has to adjust
what they’re doing based on the responses they receive. If a person becomes
more agitated as they tell their story, then seeking more information is not
helpful. Safety becomes the primary concern. Risk assessment is dynamic
and changing with new information.
Here is an example of this approach based on one case:
Subject: The IRS took all my money and I want it back!
Officer 1: Well the IRS can seize assets. Did they do that to you?
Subject: Everything, damn them, they took it all; they deserve to suffer,
those thieves!
Officer 1: How much did they take from you?
Subject: 20 million dollars!
Officer 1: That is more money than most of us will see in a lifetime. How
did you have so much money?
Subject: I sold my football team, and they took my Super Bowl ring that
gave me special powers.
Officer 1: I am sure you believe what you are telling me, do you ever
doubt yourself?
Subject: They took it all.
Officer 1: Well I hope that what you are saying is not true. I need more
information because what you are telling me is hard to believe.
Do you have any idea why?
Subject: Because they have lied.
Officer 1: Do you have a plan to get back what you believe was taken?
The officer is continually assessing how the subject of interest is re-
sponding. From a supportive distance the officer is neither directly challeng-
ing nor accepting the subject’s view of the world. Can the subject admit that
others might find their story hard to believe? It is a promising sign if the sub-
ject is able to accept that someone else might be skeptical, as it demonstrates
the capacity for empathy and the ability to step back from the brink.
Next the officer is assessing if the subject in question is aiming their
revenge at a specific target or location and has a plan. If someone is or-
ganized enough to plan, then they pose a greater threat in general and a
36 G. S. Lipson et al.
greater threat if the officer is seen as blocking their attempt at revenge. As
the interview proceeds the officer can ask about drugs, medications, and
the like. The door is opened with suspended disbelief to hear the subject’s
abilities, perceptions, and experience.
Staying calm, indicating to a person with mental illness that you will
listen to them, and that you are suspending disbelief, helps de-escalate the
situation with someone who is agitated. It is useful to recall that persons
with mental illness may have significant histories of victimization and trauma
(Maniglio, 2008). There is not one formula for responding to individuals
who are experiencing a mental health crisis. The more officers know about
mental illness, its risk factors, how to respond flexibly and appropriately, the
safer and more effective interventions can be.
Police officers will have interactions with individuals who rely on med-
ication as a significant part of their treatment regime. To adequately account
for risk during an interaction, officers need to inquire into medication that
has been prescribed, when it was last taken, and the impact of the med-
ication. Officers will find it helpful to have a working knowledge of the
principal antipsychotic medications, antidepressants, and antianxiety agents.
One can then deduce the probable underlying disease process and some of
the associated risk with that disorder.
SUMMARY
As the population of persons with mental illness grows, front-line officers
need to have strategies to respond effectively. Experiential learning can help
officers acquire skills and strategies in settings where mistakes provide new
insights and help to build a sense of competency (Reuland & Schwarzfeld,
2008). It gives them a chance to test out new modes of responding and
see likely reactions. Experiential training can include interacting with per-
sons with mental illness and families as a way of building rapport with the
community. Effective strategies based on knowledge need to replace media
depictions and stereotypes.
Dangerousness may increase if individuals with mental illness perceive
malevolence, if there is a sense that authority is out to harm them. Past
criminal history, past involuntary psychiatric hospitalizations, violence in the
surrounding environment, and having suffered repeated assaultive victimiza-
tions raise the risk for violence. The mix of severe mental illness with other
moderating factors leads to enhanced risk of violence. An understanding of
these moderating factors is crucial to violence and risk assessment. Staying
calm by monitoring tone of voice and minimizing aggressive body language
can help de-escalate a tense situation. The use of “suspended disbelief” will
further communication and mutual problem solving.
A Strategic Approach to Police Interactions 37
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual of men-
tal disorders (4th ed., text rev.). Washington, DC: Author.
Borum, R., Deane, M. W., Steadman, H. J., & Morrissey, J. (1998). Police perspec-
tives on responding to mentally ill people in crisis: Perceptions of program
effectiveness. Behavioral Sciences and the Law,16, 393–405.
Cordner, G. (2006). People with mental illness: Problem-oriented guides for police
problem-specific guides series. Washington, DC: U.S. Department of Justice, Of-
fice of Community Oriented Policing Services.
Douglas, K. S., Guy, L. S., & Hart, S. D. (2009). Psychosis as a risk factor for violence
to others: A meta-analysis. Psychology Bulletin,135, 679–706.
Fitzgerald, P. B., de Castella, A. R., Filia, K. M., Filia, S. L, Benitez, J., & Kulkarni,
J. (2005). Victimization of patients with schizophrenia and related disorders.
Australian and New Zealand Journal of Psychiatry,39, 169–174.
Flores, P. (2006). Conflict and repair in addiction treatment: An attachment disorder
perspective. Journal of Groups in Addiction & Recovery,1, 15–26.
Hodgins, S., Alderton, J., Cree, A., Aboud, A., & Mak, T. (2007). Aggressive behav-
ior, victimization and crime among the severely mentally ill patients requiring
hospitalization. British Journal of Psychiatry,191, 343–350.
James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates.
(Special Report NCJ 213600). Washington, DC: U.S. Department of Justice, Bu-
reau of Justice Statistics.
Maniglio, R. (2008). Severe mental illness and criminal victimization: A systematic
review. Acta Psychiatrica Scandinavica,119, 180–191.
Marley, J. A., & Buila, S. (2001). Crimes against people with mental illness: Types,
perpetrators, and influencing factors. Social Work,46, 115–124.
Monahan, J., Steadman, H. (1994). Violence and mental disorder: Developments in
risk assessment. Chicago: The University of Chicago Press.
Monahan, J., Steadman, H. J., Silver, E., Appelbaum, P. S., Robbins, P. C., Mulvey,
E. P., et al. (2001). Rethinking risk assessment: The MacArthur study of mental
disorder and violence. Oxford, UK: Oxford University Press.
National Institute of Mental Health. (n.d.). Statistics. Retrieved February 11, 2010,
from http://www.nimh.nih.gov/health/topics/statistics/index.shtml
Reuland, M., & Schwarzfeld, M. (2008). Improving responses to people with mental
illnesses: Strategies for effective law enforcement training. New York: Council of
State Governments Justice Center.
Reuland, M., Schwarzfeld, M., & Draper, L. (2009). Law enforcement responses to
people with mental illness: A guide to research-informed policy and practice.
New York: Council of State Governments Justice Center.
Ruiz, J., & Miller, C. (2004). An exploratory study of Pennsylvania police officers’
perceptions of dangerousness and their ability to manage persons with mental
illness. Police Quarterly,7, 359–371.
Schwarzfeld, M., Reuland, M., & Plotkin, M. (2008). Improving responses to
people with mental illness: The essential elements of a specialized law
enforcement-based program. New York: Council of State Governments Justice
Center.
38 G. S. Lipson et al.
Teplin, L. A., McClelland, G. M., Abram, K. M., & Weiner, D. A. (2005). Crime
victimization in adults with severe mental illness: Comparison with the National
Crime Victimization Survey. Archives of General Psychiatry,62, 911–921.
U.S. National Institutes of Health, National Institute on Aging. (2010). Alzheimer’s
information. Retrieved February 11, 2010, from http://www.nia.nih.gov/
Alzheimers/AlzheimersInformation/GeneralInfo/
Vickers, B. (2000, July). Memphis, Tennessee, Police Department’s Crisis Intervention
Team. Practitioner Perspectives, 1–11.
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