Dangerous mix: Law enforcement and mentally ill suspects

(Second of two parts. Click here for Part I)
Calls to ‘defund’ police gain traction, as protesters — and public officials — contend that money would be better spent if clinicians and social workers responded to mental-health 911 calls. Police say many such programs already exist, and that they need more staff and funding.  

Police response to mental-health calls often ends – again and again – in chaotic, noisy hospital emergency rooms, where staff is stretched thin, and a heart attack is likely to take precedence over someone in the throes of a mental-health crisis.

“Traditionally, people would be dropped off at the ER, and the only option was to transfer them to a psychiatric facility,” says Dr. Scott Zeller, a nationally known emergency psychiatrist and former president of the American Association for Emergency Psychiatry.

“There is finally some recognition in the halls of government that there are solutions out there.” — Scott Zeller

Zeller is vice president of acute psychiatry at Vituity, a physician-led organization that provides staffing and consulting services to medical centers nationwide. Too often, he says, patients in psychiatric crises “would be stuck for days at a time in the ER, with very little treatment.”

The widely known author of articles in professional journals and the subject of news stories,  Zeller has long pioneered, with growing success, a different kind of ER for mental-health emergencies, called EmPATH units (emergency psychiatric assessment, treatment and healing unit). In that model, patients are diverted to a specialized psychiatric ER with supportive clinical staff who assess the patient’s needs – which often means simply listening, talking, adjusting medication – and frequently leads to faster recovery and fewer subsequent hospitalizations, at considerably less cost than in a traditional hospital ER.

“There is finally some recognition in the halls of government that there are solutions out there,” says Zeller. He developed the approach – now in use in dozens of hospitals around the country and in other countries  — as chief of psychiatric emergency services at John George Psychiatric Hospital in Alameda County, where he began treating patients in crisis in a separate, supportive, home-like setting, a far cry from the tumultuous environment of a hospital ER, particularly in the time of COVID.

Like other experienced clinicians, Zeller supports changes in how law enforcement handles mental-health calls.

Dispatchers take emergency calls. Photo: Gorodenkoff, Shutterstock

“We have to look at new ways of reducing police involvement,” he said, with more mobile crisis teams that utilize social workers and other clinicians as well as police officers trained in how to deal with mental-health calls. “The devil is always in the details.”

Even with additional training, police officers and 911 dispatchers must make difficult decisions in determining whether a mental-health call requires an armed police response or an unarmed social worker skilled in deescalating confrontational behavior. Often, it requires both.  “What happens if you get there, and the person is violent, threatening family, neighbors?” asks Zeller. “There has to be coordination. You’re not going to eliminate the police altogether [from mental-health calls]. . . But there are models, really good police squads, well-trained, paired with mobile crisis teams. De-escalation is always the preferred intervention.”

Like Zeller, Dr. Amy Barnhorst, a psychiatrist who is vice-chair for Community Mental Health at UCD Health and former medical director of Sacramento County’s crisis unit and inpatient psychiatric hospital, has long been on the front lines of California’s fractured emergency response to psychiatric crises. She applauds efforts to include more clinicians in police response to mental-health emergencies. But she also knows from vast experience that’s only part of the system that has failed the thousands of homeless mentally ill people wandering California streets.

“I’ve talked to a few families who say the best thing that has happened is when they got arrested.” — Amy Barnhorst

“A lot of the patients I work with don’t have homes,” she said, “and are not receiving treatment for their mental illness. Some have been arrested for vagrancy, public urination. A mom who takes her child to the park for a birthday party doesn’t want to see a transient urinating in public, but what can we do besides throwing him in jail, when it was really that he was just trying to survive?”

Homeless people struggling with untreated mental illness, which is often accompanied by substance abuse and “self-medication,” for decades have gone to the ER – or to jail – as a default response in a grotesque system with little coordination, inadequate resources and high cost.

“I’ve talked to a few families who say the best thing that has happened is when they got arrested,” says Barnhorst, because in jail they at least have shelter and a chance at treatment. “That shouldn’t be what it takes.”

“We need more services, more funding, better coordination,” she adds, “at all levels.” Like Zeller, she advocates more “respite care,” a place for people to go for short-term treatment, rest, a path to sobriety. “They may have a suicidal break, go back to using meth. They need to have  a few nights of a safe, sober place to sleep, get into a therapy program with a counselor, drug rehab. But all of these services are underfunded, underenrolled.”

Cops as first responders
Meanwhile, cops are more often than not the primary responders to mental-health crises. “Law enforcement has a lot of other things on their plate,” says Barnhorst, echoing the widely held view of both clinicians and officers. “It’s great to have trained mental health professionals involved in the response, but I’m not sure whether law enforcement should not be there. It’s not always clear whether it’s a mental-health emergency. They may get out there and find that it is, but that’s not always clear in the call.”

““This is an absolutely appropriate time to take a look at the links between the criminal justice and behavioral health systems.” — Stephanie Welch

Barnhorst, Zeller and others point to the success of mobile crisis and community support teams of social workers, clinicians and “peer support” workers – people who may not have clinical degrees but have “lived experience” — that now exist in many counties and accompany police officers on mental-health calls. “They understand the families,” says Barnhorst, “how to de-escalate, [while] police officers are trained to neutralize a threat.”

Capitol Weekly interviewed dozens of public officials, law enforcement officers and clinicians about how to improve police response to mental-health calls, and all emphasized that law enforcement is only one piece of the puzzle, that a coordinated, collaborative approach is essential, involving community members, families and all relevant government agencies.

“The most important thing is not to look at just solving this aspect of it – police engagement and crisis response,” said Stephanie Welch, who has two decades’ experience in local and state mental-health programs and is executive officer of the Council on Criminal Justice and Behavioral Health in the state Department of Corrections and Rehabilitation, which works to prevent incarceration of people whose underlying mental illness is the root cause of their involvement with the criminal justice system.

“Otherwise, we’re missing an opportunity to take an overarching look at our overall system so that we don’t have so many people in crisis on the streets,” she said.

“This is an absolutely appropriate time to take a look at the links between the criminal justice and behavioral health systems,” Welch added. “And one thing in the COVID crisis is that we are not putting people in jail who need social services. To some extent there is an opportunity to do right by people.”

“Many  people ended up in prison because of, or largely a result of, their mental illness —  some very serious crimes, multiple murders, and others who just couldn’t function on the outside.” — Steve White

The concept of social workers and other clinicians working in law enforcement agencies is not new, but never has the public sentiment been so strong to make major changes in the way police respond to mental-health and other emergencies.

Sacramento Superior Court Judge Steve White was Sacramento’s elected district attorney in 1989 when he made the then-controversial decision to hire social workers in the DA’s office, in part to help deal with cases that involved untreated mental illness – and to support victim-witnesses in domestic violence cases who were often afraid to testify against their abusers.

White had made prosecution of domestic-violence cases a high priority at the outset, significantly increasing both staffing and prosecutions, going before the county Board of Supervisors to get additional funding for the two social workers, which at that time was highly unusual in a local prosecutor’s office. The volume of successfully prosecuted domestic-violence cases increased significantly.

As Inspector General of the state prison system (which then included both adult and juvenile corrections programs in the Youth and Adult Correctional Agency), from 1999-2003, White investigated a state prison system rife with abuse and mismanagement. “I was struck by the thousands and thousands of inmates who had mental-health issues that ran the gamut from serious to criminally insane,” he recalls. “Many  people ended up in prison because of, or largely a result of, their mental illness – some very serious crimes, multiple murders, and others who just couldn’t function on the outside.”

The man with the banana
He recalls the case of a man “going up and down K Street with a banana.” Clearly mentally ill, he was not feigning a gun, “just holding a banana and demanding money.” Despite efforts to dissuade him, some counseling, he was eventually sent to prison for robbery. “That was a failure.”

Several police reform bills are currently before the state Legislature, but none propose comprehensive changes in how law enforcement handles mental-health crises.

Appointed to the Sacramento Superior Court by then-Gov. Gray Davis in 2003, White continues to see the toll that untreated mental illness has on the criminal justice system — “the massive number of people with significant mental-health issues who are part of the criminal justice system.” He says current efforts throughout California to reform how police handle mental-health calls, with an aim to preventing incarceration, constitute “a moral and economic imperative.”

Like many judges and attorneys who work in the criminal justice system, White strongly supports including social workers and other clinicians in law-enforcement response to mental-health calls, as well as the increasing use of mental-health courts in many counties, to divert mentally ill defendants from the traditional criminal court system. But, like others, he said any real reform needs to be statewide.

Several police reform bills are currently before the state Legislature, but none propose comprehensive changes in how law enforcement handles mental-health crises. Continuing COVID restrictions and a dire state budget picture are likely to severely disrupt the remainder of the legislative session, which is scheduled to end Aug. 31.

AB 1506, by Assemblyman Kevin McCarty, D-Sacramento, would establish a separate unit within the state Attorney General’s office to investigate officer-involved use of force resulting in the death of a civilian. AB 1196, by Assemblyman Mike Gipson (D-Carson), would place a statewide ban on the use of carotid artery holds.  Both bills passed in the Assembly and now go to the state Senate.

The only bill directly addressing police response to mental-health emergencies is AB 2054 by Assemblywoman Sydney Kamlager, D-Los Angeles, which would establish pilot programs to eliminate police response to a wide range of crises involving homelessness, mental illness, natural disasters and domestic violence. It was passed by the state Assembly with bipartisan support, is sponsored by the ACLU and supported by numerous community organizations.

Substance abuse is a common cohort of mental illness, often reflecting efforts to “self-medicate.”

Called the C.R.I.S.E.S Act (for Community Response Initiative to Strengthen Emergency Systems), the measure would establish a three-year pilot program administered by the state Office of Emergency Services with grants to “no more than 12” community organizations. “We need to get away from police as first responders,” says ACLU legislative advocate Dennis Cuevas-Romero. And while he praised law enforcement “for trying to shift the narrative” with local programs that include clinicians, he said police “should focus on the real issues of danger to the community,” leaving other crisis response to clinicians and community groups.

One family’s nightmare
Rarely consulted about policy changes in how police respond to mental-health calls, family members of mentally ill relatives often tell the most compelling – and tragic — stories.

Susan Shaw Goodman – a former teacher who became an attorney, a school board member, a prosecutor and chief counsel to the Assembly Committee on Public Safety – is the mother of a 32-year-old son with severe mental illness who lives with her in Folsom.

As a former board member of the Sacramento chapter of the National Alliance on Mental Illness (NAMI), the nation’s most influential mental health organization representing families, her knowledge of the fraught state of mental-health care in California is both professional and deeply personal.

Her son, who was adopted as an infant, was a “meth baby,” the child of a methamphetamine addict who used meth during her pregnancy. He had learning difficulties in school and was placed in special education classes. His mental illness worsened in middle school, and his desperate parents spent thousands of dollars on treatment programs, at one point sending him to a highly regarded boarding school and therapy program for teens and children in Utah. Nothing seemed to help.

Using her legal skills and knowledge of the system, she has been able to get (her son) some treatment, but care is “very, very limited.”

In his early teens, he started smoking marijuana and stealing from his family – money, jewelry, family heirlooms – and getting arrested for minor crimes like petty theft. He tried different drugs – Ecstasy, heroin – and in his early 20s, he started using methamphetamine, which is highly addictive, widely available, relatively cheap and extremely destructive.

Substance abuse is a common cohort of mental illness, often reflecting efforts to “self-medicate.” He was diagnosed with depression, anxiety, anger-management issues and, ultimately, with paranoid schizophrenia, one of the most devastating of mental illnesses, often diagnosed in the late teens and early adulthood.

In telephone interviews with Goodman, her son can sometimes be heard yelling in the background. Other times, he would answer the phone, calm and courteous. “He’s not yelling because he’s angry,” says Goodman. “It just comes out.”

In 2016, he was homeless, living on the streets after another stint in jail, when he came to his mother’s Folsom home and started hurling bricks from the yard, breaking 22 windows. He was arrested and went back to jail. “I told him he couldn’t come home until I was sure he was not on drugs.”

“It’s a nightmare,” she says, “a terrible illness. . .He has very few filters, no sense of other people having feelings, no empathy – but not in a rude, nasty way. His brain just doesn’t go that far.” Using her legal skills and knowledge of the system, she has been able to get him some treatment, but care is “very, very limited.”

“To me, any officer is worth his weight in gold if he tries to keep the person out of jail.” — Susan Shaw Goodman

He sees a psychiatrist through TCORE (Transitional Community Opportunities for Recovery and Engagement) and the Hope Cooperative, nonprofit programs that partner with Sacramento County Behavioral Health to provide mental-health care and other services.

Many psychiatric medications have serious side effects, and one of the medications he is taking is known to cause involuntary yelling, which – in dangerous combination with methamphetamine use — has sometimes led to arrests. “He was arrested once while he was on meth, standing on top of a building, yelling, throwing things,” Goodman recalls.

There have been many experiences with the police. “I’ve had cops coming in and out of my house for about 15 years, including just a few weeks ago,” says Goodman. “The neighbors have called the cops twice because of my son’s yelling.”

When the police are called, Goodman says, officers’ responses “run the gamut,” from “bad attitude, telling me I need to leave town. . .” to others who engage her son in conversation, spend time with him, congratulate him on completing a drug-rehab program, come back to see how he’s doing. The latter, she said, “is so, so helpful, not to be treated like you’re the enemy and not to be trusted.”

“To me, any officer is worth his weight in gold if he tries to keep the person out of jail,” says the former prosecutor. “It can be, ‘You’re drunk, you’re high, I’m just going to take you downtown’ (to jail). That’s happened. Or, ‘Hop in the car, I’ll take you home.’ That has happened too.”

In one recent interaction, she said, in response to a complaint from a neighbor, the officer was accompanied by a social worker from Sacramento County’s Mobile Crisis Support Team, which partners with local law enforcement in responding to mental-health calls. “She listened,” says Goodman. “She showed empathy, creativity, compassion.”

Then the social worker went next door to talk to the neighbor who had filed the complaint. “About a week later,” Goodman recalls, incredulous, “the neighbor came over and handed my son a note in an envelope, and it said something to the effect, ‘Thank you so much for trying to work on your voice and keeping your windows closed, and we wish you well on your journey’.”

Goodman said she and the neighbor “hadn’t spoken in years, and my son had been a slime ball in their lives. I think it was the social worker who changed that.”
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Ed’s Note:  Sigrid Bathen is a longtime Sacramento journalist and former Sacramento Bee reporter who has covered mental-health and related issues for several publications for more than 40 years. She has taught journalism and communications at Sacramento State since 1988. She has written for Capitol Weekly since 2005, on a variety of subjects, including education and health care. To see two of Bathen’s recent pieces in Capitol Weekly on mental health issues, click here and here.