ARCHIVED - Policing Persons with Mental Illness: Issues and Trajectories

Introduction

Issues surrounding police contacts with persons with mental illness (PMI)^{Footnote 1} are by no means new. Early texts on policing often included information germane to "dealing with" cases involving PMI. The Practical Patrolman, by Gilston and Podell (1959), refers to "mentally disturbed persons" as a subcategory of "Special People."

Among the most dangerous kinds of people the patrolman is called to deal with are the mentally disturbed persons or psychos. They may be mute and docile, tearful and depressed, elated and talkative, or angry and violent. The specific medical diagnosis of their illness is not a police concern, but recognizing them, guarding against their harming themselves, others and you and turning them over to medical authorities are police matters.

Similarly, How to Recognize and Handle Abnormal People, by Matthews and Rowland (1960) includes chapters on how to tell when a person is mentally ill and how to handle a disturbed or violent person.

Implicit in these treatments were the notions that cases involving PMI regularly fell within the purview of the police and that such cases, while requiring special considerations, were not particularly problematic. Rather, such cases were seen as manageable, simply "part of the job." But also implicit in these discussions is the premise that PMI comprise a relatively small proportion of police contacts. As the number and frequency of police interactions with PMI have increased, so too have concerns about these interactions.

At the same time, there appears to have been a shift in the way in which police officers perceive their role vis-à-vis PMI . Traditionally, the handling of PMI has been regarded not as "real police work," but as "shit work" for which there is very little upside. Cases of this sort generally go unrewarded by police departments, so they can bring no honour. Instead, errors in handling PMI (such as the failure to prevent unnecessary or avoidable injury to police officers or the PMI , or the failure to meet informal departmental expectations about minimizing "down time") carry with them the potential for shame, embarrassment, and dishonour (Manning, 1984). Not surprisingly, some officers are apprehensive about taking on a role for which they have little training and about which they have little understanding (Husted et al., 1995). As expressed by former Los Angeles Police Department Chief Bernard Parks, the "police should not have to handle so many mentally ill people on the streets." What is important about Parks' statement is the focus on the quantity of PMI . Parks' comments do not suggest that PMI are not the police's problem: it is the "so many" that makes the situation problematic. While there remain police officers averse to handling cases involving PMI , an increasingly larger number of them seem to have come to accept that engaging PMI is an unavoidable part of their jobs. Still, even with this acceptance comes a range of frustrations relating to a lack of training and support within their departments, and a lack of assistance from mental health systems. From this perspective, the issue is less whether the police should be handling these cases and more how best to manage these cases.

From a legal perspective, it has long been established that "the official mandate of the police includes dealing with mentally ill persons" (Bittner, 1967: 278), that the police have a legal obligation to respond to calls for service involving PMI .

This responsibility is grounded in two legal principles: first, the protection of the safety and welfare of the public (community); and second, parens patriae, the protection of disabled citizens, members of the community unable to care for themselves (Teplin, 1984a). These legal principles are, in fact, reflected in the fundamental criteria generally used to assess whether emergency apprehension/psychiatric commitment is warranted.

It is generally taken as a given that the number of calls involving police contact with PMI has been increasing since the late 1960s and 1970s. A number of explanations have been advanced to account for this rise, the most prominent of which tend to be drawn from the psychiatric literature, including the deinstitutionalization movement, changes in civil commitment law, and the failure of community-based treatment efforts. Less prominent have been criminological approaches emphasizing factors such as the paradigmatic shift embodied in the philosophy of community policing. The heightened rate of contact between the police and PMI has been punctuated by critical incidents and high profile cases such as recent incidents in British Columbia which have served to underscore the need for a better understanding of the nature of interactions between the police and the mentally ill.

This report examines a range of pertinent issues, ranging from the scope of the problem, to the use of police discretion in cases involving PMI , to a discussion of available options for addressing the problems presently posed by police-PMI interactions.

The scope of the problem: The incidence and prevalence of police contact with the mentally ill

Although the assertion of increasing contact between the police and PMI is widespread, the empirical bases for the claim are not well established. According to Bonovitz and Bonovitz (1981), police encounters with PMI increased more than 225% between 1975 and 1979. The most commonly cited figure recently suggests that, across the US, about 7% of police contacts are situations involving the mentally ill (Borum et al., 1998), but this figure inevitably masks significant variation across departments. A survey of officers in Sydney, Australia, notes that more than 10% of police time is spent on contacts with PMI on range, and that the range of this time was substantial, from 0 to 60% (Fry et al., 2002). Canadian statistics are harder to come by, but those available attest to the frequency of contacts. A survey of three police forces in Ontario and British Columbia found that one quarter (25.7%) of officers had contact with PMI at least once a week, and that three quarters (75.7%) have similar contacts one or more times a month (Cotton, 2004). A recent study of the Vancouver Police Department finds that 31% of calls for service involve at least one mentally ill person; in some areas, the proportion is almost half (Wilson-Bates, 2008). Given that Vancouver is possibly unique with regard to this issue, it would be unwise to generalize from this study. Consequently, the rate of police contacts with PMI remains unknown.

Although there is a lack of systematic information, it is readily apparent that the majority of police contacts with PMI involve less serious offences and behaviours that barely rise to the level of crime. Wells and Schafer (2006) found that only 1% of contacts were calls for service about a "serious crime." In contrast, 69% were calls for "general order maintenance" and 8% for "minor crime." Fully 22% of contacts were categorized as "other." Where a crime underlies the contact, only 2% of cases related to "violent and property crime," while 85% were for "order-related crime." Green (1997) uncovered a similar pattern: 27.7% disorder conduct, 7.5% trespass, 6.1% contempt and 13.4% all other. Interestingly, "no offences" was recorded for 45.3% of cases. Results such as these support what in the literature is a routine characterization of contact-inducing behaviours as minor nuisances and transgression relating to public order.

The lack of information regarding incidence notwithstanding, the perception among police officers and managers alike is that these situations pose substantial operational difficulties, consume a disproportionate amount of patrol time and resources, carry with them the potential for departmental liability, and risk overloading correctional systems with relatively non-serious offenders (Hails and Borum, 2003). Moreover, many departments have faced harsh criticism and even litigation in the wake of highly publicized cases involving the use of force, including deadly force, against PMI (Hill and Logan, 2001). For all of these reasons, interactions with PMI have come to represent a major concern for many police departments.

Reasons for increased contact

A wide variety of explanations for the increased rate of contact between the police and PMI have been proferred. The three most common of these are derived from what might best be described as a psychiatric perspective. There are, however, a number of more criminologically-based orientations that similarly merit attention.

In general, three interrelated factors have been implicated in the rising number of police incidents involving PMI : the deinstitutionalization movement, changes in civil commitment laws, and insufficient funding for community-based programs. In the US, early interest in the idea of community-based (as opposed to institutionally-based) mental health service delivery began in the 1930s, when some psychologists began to argue that mentally ill patients would benefit more from diagnosis and treatment than from institutionalization. This perspective was formalized in 1946 with the passage of the National Mental Health Act, which authorized funding for research, training, and technical assistance for the "improvement of the mental health of the people of the United States" (Gillon, 2000). The Act also created the National Institute of Mental Health and charged it with the oversight of these programs. Advocates of community-based intervention maintained that the practice of warehousing mental patients in asylums was inhumane and not conducive to treatment. Moreover, by the mid-1950s, state governments were increasingly unable to meet the fiscal burden generated by the system of asylums and became incapable of adequately managing mental illness. At the same time, the discovery of new antipsychotic drugs such as chlorpromazine (Thorazine) brought hope that patients could be treated and live on their own (Gillon, 2000). Finally, the gradual emergence of media portrayals of the deplorable conditions in asylums periodically caused public outcry and focused attention on the plight of the mentally ill (Lamb, 1982). All of these conditions culminated, in 1961, with the Joint Commission on Mental Health calling for the deinstitutionalization of the mentally ill and for the establishment of community-based treatment centers (Lewis et al., 1991).

The deinstitutionalization movement of the 1960s and 1970s resulted in a dramatic reduction in the number of individuals confined to mental hospitals (Kupers, 1999). Advocates of deinstitutionalization maintained that PMI would be more appropriately treated through community-based programs. This transfer of PMI to a more community-based approach was further facilitated by a number of landmark legal decisions, the development of psychotropic drugs, and the incentives of proposed cost savings (Murphy, 1986). While community-based treatment is successful in many cases, its effectiveness is contingent on persons recognizing their illness, choosing to seek treatment, and maintaining their programs (Perkins et al., 1999). When these conditions are not met, and treatment is not successful, some resultant behaviours bring PMI into contact with the police.

Concomitant with the deinstitutionalization movement, changes to the law made it much more difficult to have people involuntarily committed. In California, the Lanterman-Petris-Short Act of 1968 highlighted the civil rights of psychiatric patients and made involuntary commitment a much more complex process (Lamb, 1982). The Act would serve as a blueprint for other jurisdictions, and eventually 36 out of 50 states embraced more stringent criteria for civil commitment (Phelan and Link, 1998). PMI can only be committed to psychiatric hospitals if they present a danger to themselves and/or others, and that dangerousness must be attributable to their mental illness (Stefan, 1996).

In concert, the changes wrought by these two movements served not only to bring the police into greater contact with PMI , but also to limit the dispositional alternatives available to the police in these instances. For their part, the police have tended to express resentment toward the policies of deinstitutionalization. Despite the significant impact it was likely to (and in fact did) have on law enforcement, deinstitutionalization was done unilaterally, without consultation with the police. Moreover, the changes in commitment law have played a role in fostering the often factious relationship between the police and mental health professionals. The police argue that the mental health professionals too often fail to validate police assessments of dangerousness, while clinicians respond that the police do not "bring them the right patients." Insofar as deinstitutionalization and legal changes may have had some unanticipated deleterious consequences, the police are less than sympathetic. The attitude of many might best be summed up with these sentiments: "The mental health field owns the responsibility for the breakdown in treatment for the insane – not the police. You guys broke it – you fix it" (Gillig et al., 1990: 665).

The third reason for increased police-PMI contacts lies in the failure of post-deinstitutionalization policies and practices. Deinstitutionalization was never properly implemented, and the expressed intent of shifting treatment to community-based alternatives was never fully realized (Lurigio, 2000). The stated goal of reducing the populations of state facilities was realized, but reductions in government spending on mental health have limited the availability of treatment programs (Finn and Sullivan, 1989). A large percentage of PMI , most notably younger persons with the most severe and chronic mental disorders, have not received appropriate, adequate, or well-coordinated treatment in the community (Shadish, 1989). Without adequate treatment or supervision, many PMI progressively decompensate. As their conditions deteriorate and their behaviour becomes more erratic, they find themselves on the streets, coming into contact with police officers on an increasingly frequent basis (Cooper et al., 2004).

Taken together, the three interrelated factors of deinstitutionalization, changes to commitment laws, and the insufficient funding of community-based programs comprised what might be referred to as the "psychiatric" perspective on the question of why there has been an increase in contacts between PMI and the police. The approach grounds its explanations in the functioning (or dysfunctioning) of the mental health system, and there is little doubt that the confluence of these three factors has played a key role in elevating contacts with PMI to being a major concern for law enforcement. But the focus on "psychiatric" perspectives has overshadowed a variety of other important considerations of a more "criminological" nature. Put another way, there are a number of factors related more to the realm of criminology that have similarly increased PMI -police interactions but which have little to do with the mental health system. For example, the mental health system is not the only system that has failed a large proportion of PMI ; social service networks have been equally as ineffective and negligent. Adequate, stable housing, or the lack thereof, has contributed to the visibility or "publicness" of PMI . Homelessness has also been found to be related to treatment non-compliance (Wolff et al., 1997). Assistance with substance abuse has similarly been found wanting. As will be discussed later, many people with PMI have co-occurring drug and alcohol dependencies which greatly complicate both their psychiatric conditions and their prospects for treatment. The cracks though which PMI fall are many and varied, and improvements in mental health care will necessarily require enhancements in social support functioning as well.

More broadly, little attention has been paid to the neighbourhood contexts within which PMI reside. Because many persons with serious mental illness are poor and unemployed, they tend to live in the types of areas where police contacts are more frequent (Silver, 2000a, 2000b). Overall, the majority of requests for police assistance, not merely for mental health but for assistance of any kind, come from lower income people who reside in the impoverished sections of the community. It stands to reason that the use of the police as a referral agency in the cases involving PMI is higher for persons of lower socio-economic status (Pogrebin, 1986). In part, this reflects a matter of access, as people with less access to the mental health system nonetheless retain access to the police.

In these depressed areas police are called upon often to serve as a surrogate parent, to substitute for social workers, housing inspectors, lawyers, psychiatrists, and physicians. It is also in these parts of the community that police must aid those who are unable to help themselves: the destitute, the chronic drunks, the addicted, the mentally ill, the senile, the alien, the physically disabled and young children. (Goldstein, 1977)

For a host of day-to-day problems, the police have increasingly become the default agency for community members who have nowhere else to turn; they are the institution of last resort, the system that cannot say no.

There are, additionally, policing-related factors that shape the prevalence of police involvement with PMI . First, police officers know much more about mental illness than they did in the past. As a result, they are better able to recognize and categorize events as mental health cases (Bonovitz and Bonovitz, 1981). At the same time, dealing with cases of mental disorder is also more consistent with the philosophical tenets of community policing, which has come to be the dominant model of law enforcement. The shift from more traditional modes of policing to the community policing model has placed greater emphasis on the order maintenance and service-oriented aspects of the police role. As a result of this shift, many police departments are reconsidering their role in the community, particularly as it relates to more service-oriented calls. The function of the police has expanded beyond traditional law enforcement activities to encompass more service and assistance tasks. Part of this expansion of services involves assuming greater responsibility for protection of and service to vulnerable populations, including people with disabilities (Borum, 2000; Sellers et al., 2005).

Finally, the rate of police contacts with PMI are mediated both by the nature of the behaviour of PMI and societal reactions to that behaviour. There is considerable and heated debate over whether PMI are in general more likely than any other segment of the population to engage in criminal violence. Although the overall debate remains unresolved, it does appear that specific subsets of circumstances do raise the potential for violence, and with it police intervention. For example, mental illness in conjunction with substance abuse has been found to increase rates of violence dramatically (Swanson et al., 1990). The same may be said of those that are actively psychotic at the time of the event (Link et al., 1992). Young adult chronic patients also represent a difficult group. These PMI have been characterized as "aggressive and basically noncompliant persons [...] whose low frustration tolerance and impulsive behaviours frequently result in encounters with the law" (Bachrach, 1982). One study qualified its conclusion that the concurrence of mental illness and violence constitute the smallest category of incidents by noting that a large number people, while not violent, are nonetheless "threatening" (Panzarella and Alicea, 1997). On the other hand, it is well established that the vast majority of PMI do not come to the attention of the police through an act of violence. On the contrary, most PMI come into contact with the police for relatively minor complaints or offences, such as "suspicious person" or "disorderly conduct" (Green, 1997; Wells and Schafer, 2006). Clearly, the dynamics of these situations implicate not just the behaviour of the suspect, but the reaction of the community to that behaviour. Simply put, tolerance for aberrant behaviour has, in many communities, become very low. This is also reflected in aggressive, "zero tolerance" policing approaches that afford the police tremendous latitude in addressing what may be characterized as "quality of life" offences (Markowitz, 2006). As a consequence, part of the rise in police-PMI interactions may be attributed to the hypervigilant responses of community residents (Wolff et al., 1997).

In sum, while empirical evidence quantifying either the incidence or change in incidence of police contacts involving PMI remains elusive, there is abundant circumstantial evidence to suggest that the rate of occurrence has, for some time, been increasing. A wide variety of factors have conspired to produce these rising level of interaction, and the problems attendant with them. One of the earliest and most pervasive problems was that of criminalization.

The criminalization thesis

By the early 1970s, PMI were consistently found to be overrepresented in jails and prisons, a condition Abramson (1972) termed the "criminalization of the mentally ill." At the heart of the criminalization thesis rest assumptions about the appropriateness of arrest as a disposition for PMI . In her seminal work on criminalization, Teplin (1984b) found that, for similar offences, persons with mental illness were significantly more likely to be arrested than were persons without mental illness. She further concluded that "the way we treat our mentally ill is criminal" (799).

Because the police are often put in the position of having to decide whether citizens will proceed into the criminal justice or mental health systems, they have been described as "forensic gatekeepers" (Menzies, 1987). And because most officers are not clinically trained, they are also regarded as "psychiatric medics" (Menzies, 1987), "streetcorner psychiatrists" (Teplin and Pruett, 1992) or "amateur social workers" (Cumming et al., 1965). To the degree that the police function as gatekeepers, they too have been indicted for their role in the criminalization of PMI . Critics maintain that the police fulfill their gatekeeping function in such a manner that many potential clients are denied access to available community services (Hanewicz et al., 1982). The presumption has been that the police are too eager to resort to arrest in calls involving PMI , and that better use should be made of dispositional alternatives.

It is important to note, however, that even staunch criminalization advocates do not lay the blame solely on the police. For example, Teplin acknowledges that the disproportionate pattern of arrests may be an "indication of the burgeoning interstices between the various health care delivery systems" (1984b: 800). By virtue of their mandate, the police do not have the option of looking the other way. Once they are engaged in a situation, they must bring it to some resolution. If there are no appropriate alternatives, the police may arrest a PMI , even if the infraction is minor. The police in many jurisdictions are all too aware of the lack of psychiatric beds and limited community mental health services. In some cases, the police may engage in "mercy booking," believing that PMI are more likely to receive psychiatric treatment in prison than in the community (Lamb et al., 2002; Menzies, 1987). At the same time, the police are cognizant of the criteria for hospitalization and commitment, and realize that a number of conditions will preclude the mental health system from receiving PMI , including persons who are intoxicated or too combative or violent. In these instances, arrest is not only more expedient, it may be the only plausible disposition.

The police have numerous reasons for wanting to avoid the mental health system, which they find both problematic and aggravating. They are often forced to wait for longer periods of time while waiting for an assessment. As departmental supervisors tend to emphasize a quick resolution to issues so that officers may return to their duties, these long periods "off the clock" prompt considerable stress. Mental health professionals occasionally question the judgment of police officers. They may refuse to admit the person, or discharge them after a short period of time, producing a "revolving door" effect that requires the police to deal with the same individuals over and over again (Lamb et al., 2002). By contrast, arrest and subsequent commitment to the criminal justice system is more familiar and predictable for the police.

For many years, the criminalization thesis went largely unchallenged. More recently, contrafactual evidence has begun to emerge, and it is less clear that the disproportionate number of PMI in jails and prisons is solely attributable to inappropriate police conduct (Engle and Silver, 2001). Cotton (2004) notes that situations involving otherwise non-criminal behaviour, when attributable to PMI , might result in arrest simply because no other solution presents itself. There is also a more fundamental issue concerning the assumptions of criminalization; specifically, that all arrests of PMI are prima facie inappropriate. Kalinich and Senese (1987: 189) argued that

[i]t seems to us that the only way to argue that mentally disordered offenders are being criminalized [...] is to believe that all offenders with signs of mental disorder should be placed in the custody and control of the mental health system and none should be arrested.

The issue should not hinge merely on whether PMI are arrested, but instead on the appropriateness of the arrest in the particular circumstances in question. In other words, more important than criminalization per se are the rationale underlying police decision making and the manner and context within which police discretion is exercised.

Police discretion

In their role as frontline mental health workers, the police exercise a tremendous amount of discretion (Green, 1997). In many cases, police officers have wide latitude in determining the outcome of cases involving PMI . In general, three dispositional options are available: informal resolution, arrest, or placement with mental health authorities through either civil commitment or emergency hospital evaluation (Steadman, 1992). Informal tactics may include trying to "calm" the PMI , moving the PMI to another location, or releasing the PMI to a third party such as a neighbour, friend, or relative. Because the informal handling of cases avoids contact with the mental health system as well as the paperwork associated with arrest, police officers tend to favour handling these incidents in this manner, and the majority of incidents are resolved accordingly (Bittner, 1967; Teplin and Pruett, 1992).

One of the reasons the police are afforded such wide latitude in dealing with PMI is that many of these contacts are relatively minor in nature. Police discretion generally varies along a continuum of severity, with more serious conduct tending to constrain available dispositional alternatives. Incidents involving PMI most often feature behaviour that is relatively petty, troublesome but not criminally serious or violent. Under these circumstances, the police may choose from a broader pallet of options, at least in theory. There are, however, a number of factors beyond the specific type of offence that may impinge upon discretionary decision making. In trying to understand the police-PMI nexus, it is important to try to unravel those considerations that may influence police discretion.

Contextual factors

Some factors that affect significantly the options available to the police have already been identified. For example, the legal context makes it exceptionally difficult to involuntarily commit PMI to mental health facilities. As well, many facilities have limited space, especially for police referrals (Finn and Sullivan, 1989). Both of these conditions would seem to steer the police away from these institutional responses. In many jurisdictions, access to mental health options is further complicated by the less than stellar rapport between the police and mental health service providers. Police officers routinely argue that hospital assessments take too long, and they express frustration at what they perceive to be a lack of faith in, and validation of, the judgments they make in the field. Thus, police discretion is restricted by the availability and receptivity of mental health agencies (Engel and Silver, 2001).

Police officer discretion is also limited by departmental considerations. Most departments operate with scarce resources, and encourage officers to revolve cases quickly so that they may move on to the next one. In the cases of mentally ill offenders, there is a substantial amount of institutional pressure from the police department to solve these cases on an informal basis (Green, 1997). At the same time, the broader social context requires the police to intervene with PMI with greater and greater frequency. As was suggested earlier, many community residents appear to have a low threshold of acceptance for erratic behaviour, about which they demand that the police "do something." This intolerance of aberrant conduct may be exacerbated by prevailing urban trends such as gentrification, which increasingly bring non-mentally ill residents into close proximity with persons with mental illness.

Situational factors

Previous research has established that the characteristics of an encounter situation influence police behaviour. As noted earlier, perhaps the most salient situational factor in police-PMI interactions is the severity of the behaviour that precipitated the encounter. More serious behaviours carry with them higher risks of police use of force and arrest, regardless of whether mental illness is an issue. In addition to the nature of the action, situationally-relevant considerations include, but are not limited to: who lodged the complaint; the relationship between the parties involved; the history of that relationship; the history of the relationship between the police and the suspect; whether the suspect is a "known neighbourhood character;" and the "publicness" of the incident.

With regard to the parties lodging the complaint, Rogers (1990) showed that it was rare for officers to initiate contact with PMI (8% of cases). In most cases, it was members of the public that called for assistance, setting up a situation that necessarily required some sort of "resolution." Moreover, the police differentiate between responses consistent with the nature of the party making the request. Bittner (1967) found that the requests for hospitalization made by persons standing in an instrumental relationship to the PMI , such as doctors, teachers, employers or landlords, were generally honoured by the police, the assumption being that these parties had already exhausted other alternatives and that emergency apprehension was therefore the only means available. In contrast, Bittner noted that similar requests made by more personal relations, such as neighbours, friends, and family members, were usually not honoured. However, while the police may be reluctant to institutionalize at the behest of family and friends, they are usually willing to leave a PMI in the care and control of family and friends as a means of informally resolving a situation.

Teplin (1984a) has identified a typology of mentally ill persons who are most likely to be handled informally. First, neighbourhood characters are community residents well known to the police working in the area. Because these PMI are "known quantities," the police have developed certain expectancies about the parameters of these persons' behaviour. This familiarity allows the police to informally "cool out" the PMI . So long as the behaviour remains within the bounds anticipated, the police are more tolerant of a degree of deviance that would, if it came from a less known person, elicit a more formal response. Second, troublemakers are persons who are simply "not worth the hassle." Teplin use the example of a woman who would, whenever arrested, "take off her clothes, run around the police station naked, and urinate on the sergeant's desk" (1984a: 172). Although these PMI occasionally warrant intervention, the police try to avoid arrest. Finally, unobtrusive mentals are regarded as more disordered than disorderly. Because they are relatively quite and unobtrusive, their conduct is less offensive to both the public and the police.

The last point regarding obtrusiveness or "publicness" is important in understanding police discretionary decisions. At the broadest level, the criminal justice system has always been charged with the maintenance of public order. Offences such as public drunkenness and vagrancy reflected early prohibitions on activities that were notable primarily because they disturbed the peace or threatened good public order. In the contemporary context, the advent of the "broken windows" (Wilson and Kelling, 1982) approach to crime control has made public order a particularly salient consideration. Indeed, much of the discussion surrounding the policing of marginalized groups is premised on conflict over public space. That is, it is the public nature of panhandling and public injection that brings the homeless and drug addicts respectively into contact with the police. This same principle may be seen in police contacts with PMI , in that there is an inverse relationship between how public the PMI conduct is and the ability of the police to act informally. PMI who are quiet and "keep to themselves" are unlikely to be sanctioned formally. But as the level of "publicness" of the manifestation of mental illness rises, so too does the probability of formal resolution. Simply stated, police discretion is limited to the extent that the behaviour in question is too public to be ignored (Teplin, 1984b)

Police officer characteristics

That a wide array of characteristics peculiar to the officer(s) in any specific incident may influence decision making has long been recognized in the general literature on police discretion. But many of these characteristics have been absent in the studies on policing PMI . Much of the research in this area has focused on police attitudes toward PMI . At present, there is less information regarding demographic characteristics such as sex, age, race, level of education, and experiential factors such as number of years on the job.

With regard to attitudes toward the mentally ill, the primary concern has been whether police officers share the same negative views that tend to characterize the general public. Despite the importance of establishing a comparative baseline for officer attitudes, little research has been conducted in this area. Early studies suggested that while the police were not overly prejudiced against the mentally ill, they did have harsher attitudes than did mental health professionals (Lester and Pickett, 1978). However, more contemporary research has tended to be more positive. A key examination of attitudes among Canadian police officers found that they generally demonstrated moderately high levels of benevolence, moderate levels of community integration, and lower levels of authoritarianism and social restrictiveness (Cotton, 2004). Research using vignettes similarly concluded that the police officers viewed PMI as being less responsible for their situation and more worthy of assistance (Watson et al., 2004a).

These less negative views notwithstanding, many police officers continue to regard the mentally ill as being dangerous. Although the incidence of violence in contacts with PMI remains low, a significant proportion of officers agree with the statement "persons with mental illness are dangerous" and express that they feel "uneasy," "worried," or "threatened" during these interactions (Ruiz and Miller, 2004). That police officers hold seemingly contradictory views may account for apparent disjunctures between attitudes and behaviours. Trovato (2000) determined that while officers expressed positive orientations and a sense of obligation toward PMI , their behaviour was more consistent with authoritarian and socially restrictive views. More generally, findings such as these demonstrate the difficulty of conclusively linking attitudes to behaviour. Specifying how attitudes and opinions may influence discretionary decision making is not as straightforward as ascertaining whether police officers maintain positive or negative views of PMI . There are competing interests at work, producing a complex of attitudes and opinions. As such, the link to actual behaviour remains elusive.

Further complicating the situation is the fact that, while the literature examining the role of various demographic factors in relation to police decision making in a universal sense is extensive, research on the demographic determinants of decision making and the exercise of discretion in specific cases involving PMI is extremely limited (Cooper et al., 2004; Engel and Silver, 2001). Green (1997) found that police officers' years of experience was negatively related to the probability of arrest and positively associated with a disposition of "no action taken." LaGrange (2003) has similarly shown that officers with four-year degrees were significantly less willing to arrest PMI than were officers without four-year degrees. Beyond these snippets, information in this area remains scant; research on police officers' characteristics, beyond their attitudes towards PMI , is badly needed.

PMI characteristics

As with police officers, many of the characteristics associated with PMI that might be relevant to understanding police decision making have similarly been underresearched. In the majority of studies the PMI remain relatively undifferentiated; only a couple even distinguish between the PMI as suspect, witness, or victim. Very few of the studies consider the sex or age of the PMI , although anecdotal evidence suggests that both females and youths are notably represented in this group. There is also a paucity of research on urban Aboriginals with mental illness, despite the importance of this population in Canadian cities. Even the very nature of mental illness has not been explored at great length, although what little information there is suggests that different disorders present differently and therefore prompt disparate reactions on the part of the police.

There is some research on the effect of demeanour in police-PMI interactions. Studies on non-disordered offenders have routinely found that acts perceived as "defiance of authority" or "disrespect" prompt more severe and punitive responses, including arrest, from the police. There is evidence, however, that this pattern does not hold true for PMI . Although mentally disordered suspects were more likely to demonstrate resistant, hostile, or disrespectful behaviour, they were significantly less likely to be arrested (Novak and Engel, 2005). Novak and Engel further posited that officers may use cues about the mental status of the suspect to determine culpability or "deservedness." To date, comparable studies have not been reported, so there is no way to know the extent to which these findings may be replicated.

Overall, not nearly enough is known about the factors that impinge upon police decision making in relation to PMI . Additional research is needed across all levels, particularly as it relates to the immediate parties, the police and the PMI .

Police use of force

In general, baseline data on the police use of force in cases involving PMI is hard to come by. While the number of incidents involving psychical conflict and violence are relatively small, stereotypical views of the mentally ill as "unpredictable" and "dangerous" elevate the importance of use of force issues. Few PMI actively resist the police or become violent, but given the potentially dire consequences, the police are concerned about these interactions nonetheless (Kaminski et al., 2004). Additionally, when the media seizes on stories involving the police and PMI , they invariably involve the use of force, and especially lethal force, against PMI . For these reasons, police use of force in the context of interactions with PMI warrants consideration. Unfortunately, this is another area characterized by sparse information.

A number of approaches have been advanced to explain why PMI might be more likely to experience higher levels of force. One line of reasoning links the use of force to police attitudes towards the mentally ill. Police officers tend to view the mentally ill as unpredictable and dangerous, and approach them accordingly. Ruiz and Miller (2004) frame this as a "self-fulfilling prophecy." The police, anticipating a potentially dangerous encounter, experience fear and apprehension. These emotions are reflected back to the PMI as hostility, which triggers a hostile response in return. Thankfully, research has not substantiated the self-fulfilling prophecy hypothesis (Ruiz and Miller, 2004).

Another perspective also rooted in the traditional approach of police officers is offered by Fyfe (2000), who argues that police training may contribute to some of the difficulties in encounters with PMI . Much police training emphasizes gaining compliance without the need for actual force. Officers are trained to establish authority by approaching suspects forcefully. However, this approach is premised on assumption that the suspect is rational. In contrast, irrational suspects may respond by becoming frightened, disoriented, and potentially aggressive.

In these cases, the forceful police approaches that work so well with rational offenders  – threats, intimidation, closing in on personal space – are liable to force unnecessary confrontations and to put officers into perilous circumstances from which they can extricate themselves only by resorting to the most extreme types of force, that is, by shooting". (Fyfe, 2000: 346)

Fyfe further argues that some concepts currently in vogue, such as the 21-foot "zone of safety," inculcate in some officers the belief that homicidal maniacs lurk around every corner, thereby turning every street encounter into a life and death situation. Again, training of this sort undermines the type of approaches that are more effective in dealing with PMI .

One of the immediate problems in research on the actual (as opposed to potential) use of force is the fact that the concept of "impaired judgment" if often undifferentiated; that is, no distinction is drawn between impairment caused by drug use or intoxication, and that attributable to mental illness. Numerous studies have shown that police encounters with "impaired persons" are more likely to involve the use of force than are encounters with persons that are unimpaired (Friedrich, 1980; Worden, 1995; Crawford and Burns, 1998; Engel et al., 2000; Garner and Maxwell, 2001; Terrill and Mastrofski, 2002). Only one of these studies, however, attempted to separate mental "impairment" from behaviour produced by the effects of drugs and/or alcohol, and that study concluded that mental impairment was not significantly associated with the use of force (Terrill and Mastrofski, 2002). Kaminski et al. (2004) also found that the effect of perceived mental status was statistically unrelated to the use of force. Of course, two studies cannot be considered definitive, and the question of whether police responses, including the use of force, differ according to the specific "cause" of the impairment remains an open question. More generally, a clear correlation between impairment and the use of force has yet to be established.

Addressing the issue of PMI

Policies and protocols

The difficulties presented by situations involving PMI are exacerbated by the fact that most police forces do not provide clear guidelines for interacting with PMI (Patch and Arrigo, 1999). This relative lack of direction means that officers are left to resolve situations on their own. It also helps to explain why the exercise of discretion is so important in these cases; without a clear mandate, officers are more apt to make decisions by drawing on their own attitudes, perceptions and assumptions. The lack of written policies and procedures for managing PMI is consistently cited in cases where the police are held to have comported themselves improperly. Not surprisingly, suggestions for improving departmental responses to PMI normally begin by recognizing the need for formal policy (Ruiz and Miller, 2004; Watson et al., 2004b). Unfortunately, the precise content of such guiding policies is left unspecified. In most cases, some mention is made of one or a combination of a) training; b) interagency cooperation and collaboration; and c) specialized programmatic responses.

Training

That the police traditionally have received little or no training pertinent to the identification and handling of mental illness is the single most commonly cited shortcoming in accounting for the problematic nature of police encounters with PMI (Lamb et al., 2002). The Police Executive Research Forum has recommended that officers receive between 16 and 22 hours of training on all relevant issues pertaining to PMI (Murphy, 1986), but on average officers receive far less (Husted et al., 1995). And while it is difficult to determine the "adequate" level of training in any absolute sense, some have questioned whether the four to six hours most commonly reported is enough (Hails and Borum, 2003). Such a limited exposure is particularly concerning given anecdotal evidence suggesting that some training covers all aspects of mental impairment and not just mental illness. Police officers themselves routinely express both frustration at the fact that they are insufficiently trained to deal with PMI and a desire to learn more about working with them more effectively (Cooper et al., 2004; Vermette et al., 2005).

For these reasons, improved education and training have been at the forefront of efforts to improve police handling of PMI . Beyond this general desire to implement improved training, however, the shape and particulars of training remain sketchy. One issue that is rarely addressed is the content of training programs. Given that officers do not exhibit a high level knowledge specific to the policing of the mentally ill (Cotton and Zanibbi, 2003), it is important to increase knowledge about mental health overall. More specific topics would presumably include how to recognize mental illness, how to handle PMI (especially violence and potential violence), how to access community resources, suicide prevention, and verbal skills to de-escalate conflict (Borum, 2000; Lamb et al., 2002). In contrast, one of the few studies that directly inquired of officers what kind of training they were most interest in found that topics such as Management of Problem Behaviors, Mental Health Resources in Your Area, and Specific Types of Mental Illness, while important, ranked lower in preference. Instead, officers expressed greater enthusiasm for topics such as Dangerousness, Suicide by Cop, Mental Health Law, and Your Potential Liability for Bad Outcomes (Vermette et al., 2005).

While understandable, a focus on these sorts of issues underlines the extent to which thinking about violence and negative outcomes dominates in the minds of many police officers. It also reinforces Fyfe's (2000: 346) belief that "some training on this subject may actually be worse than none." It is not enough merely to add hours of training. It may similarly be important to modify existing training practices, and ensure that training is not "sending the wrong message." The phrase training by trauma has been used to describe the use of graphic visual presentations to demonstrate the consequences of the failure to employ force appropriately (Dupont and Cochran, 2000). This method of training raises officers' anxiety level and minimizes the probability that alternative conflict resolution techniques will even be considered, much less employed. This approach also emphasizes outcome and ignores the process that leads up to and ultimately produces the event. It is this process that needs repair, and generic training will not necessarily be effective in this regard.

Three outcome measures have been utilized to evaluate the efficacy of training programs: knowledge of mental illness, attitudes toward PMI , and changes in job-related behaviour and performance (Borum, 2000). There is some evidence that training may improve police officers' degree of knowledge about working with PMI (Godschalx, 1984) and ability to distinguish mental illness (Janus et al., 1980), but the ability of these initiatives to effect significant change in terms of behaviour has not been established. The equivocal nature of the results of police officer training led Borum (2000: 333) to argue that

education programs and crisis intervention training are probably not harmful and may be helpful, but there is good reason to believe that they are not sufficient to change fundamentally the nature of police encounter with mentally ill persons in crisis.

Because a traditional tenet of policing holds that extra training remedies all ills, it is important to note that training is not a panacea (Dupont and Cochran, 2000; Wells and Schafer, 2006). First, as Fyfe noted, the wrong training can produce more deleterious consequences than no training. Second, while improving knowledge is valuable, training that does not change attitudes and particularly behaviours is unlikely to substantially improve police interactions with PMI . And third, there may be circumstances in which more specialized response alternatives are more appropriate. As the call for education and training will continue, so too must vigilance regarding the implementation and evaluation of these programs.

Interagency collaboration and cooperation

While much of this report has focused specifically on the role of the police, solutions to the issues identified here require the assistance of a broader range of groups and agencies. The importance of networking has been identified by several authors, who cite special arrangements whereby law enforcement and mental health or social services share responsibility for the mentally disordered (Finn and Sullivan, 1989; Olivero, 1990; Wolff, 1998). As well, these collaborations are consistent with the philosophies of community policing and problem-oriented policing, orientations that promote closer working relationships between police and other service providers (Cordner, 2000). The primary difficulty with the development and maintenance of collaborative efforts lies in the strained relationships between law enforcement and mental health. Both groups have distinct ideologies and goals, and experience has fostered mutual distrust on both sides. On the other hand, there are numerous examples of successfully implemented cooperative programs. Better working relationships with mental health providers could alleviate many of the contextual difficulties that confront the police when determining how to resolve cases involving PMI . Simply stated, substantive improvement in the handling of PMI requires collaborations.

Programs

Numerous and variegated programs have been implemented in attempts to improve the efficacy of police responses to PMI , and research evaluating the utility of these approaches has begun. Most programs fall into one of three categories (Deane et al, 1999). First, police-based specialized police response models involve sworn officers who have special mental health training. These officers serve as the first-line police response to mental health crises in the community and act as liaisons to the formal mental health. Second, police-based specialized mental health response models utilize mental health professionals (not sworn officers) employed by the police to provide on-site and telephone consultations to officers in the field. Third, mental-health-based specialized mental health response models are more traditional partnerships or between police and mobile mental health crisis teams (MCTs) that exist as part of the local community mental health services system and operate independently of the police department.

Despite the enthusiasm of advocates, research findings do not firmly establish the superiority of specialized programmatic responses. Many evaluations are very positive, but negative findings are underemphasized. Scott's (2000) results showed that mobile crisis programs were more cost efficient than "regular policing," and that both consumers and police officers had highly favourable opinions about the program. Conversely, no significant difference in the rates of arrest between the mobile crisis teams and regular police was evident. Another evaluation of the Crisis Intervention Team (CIT) concluded that the program was valuable in assisting "individuals who are experiencing a mental illness crisis and interacting with the criminal justice system to gain access to the treatment system," despite the fact that the rate of arrests by specially trained officers actually increased (Teller et al., 2006:237). The authors' speculation that the CIT was being referred the more challenging cases was unsubstantiated and provided a stark contrast to the otherwise glowing assessment.

Borum and colleagues (1998) asked officers in three different departments (corresponding to the three program types listed above) to rate program effectiveness on the basis of four criteria: meeting the needs of PMI ; limiting jail as a disposition for PMI ; minimizing the amount of time officers are required to spend on calls involving PMI ; and maintaining community safety. The results for the CIT in Memphis (a police-based specialized police response), ranging between 53.8 and 70.7% agreement on the four indicators, were characterized as highly effective. The results for the other two sites, which ranged between 39.7 and 52.7% for all items except minimizing the amount of time spent on cases, were reported as being moderately effective. At best these are "glasses half full" characterizations. More realistically, the results for the Memphis CIT program are good, not outstanding, and the remaining programs have effectiveness ratings hovering around 50%.

More generally, there is little evidence that specialized programs are any more effective than non-specialized responses. Although Deane and colleagues (1999) concluded that all of the specialized strategies were rated relatively high, between 67 and 82%, none of the programs were perceived as being significantly more effective than the control category of "no specialized response." Similarly, research that replicated the Borum et al. (1998) study, but added Newark as a control group (because Newark has no specialized response to PMI ), found that actual and perceived effectiveness in Newark was comparable to or better than that observed in relation to specialized programs (Sellers et al., 2005). As was the case with training, specialized programming is not a panacea. The implications of these results call into the question assumptions about the utility of specialization as the most appropriate response in all circumstances:

These results indicate that a community with a traditional "treatment as usual" response to persons with mental illnesses can be effective in dealing with this special population. Although the Memphis program appears to be the most effective model observed here, it is clear that the Newark approach works as well as the others. At the same time, this approach does not require the redirection of resources to a "specialized" population that may be managed more effectively with a more traditional response. There is a real concern that departments may widen the net when implementing programs designed to deal with a specific subpopulation. Ultimately, police agencies must consider their resources, the capacity for sharing the burden of response with other local agencies, and the specific nature of their problem in responding to persons with mental illnesses. This will ensure that costly redundancies are not introduced into agencies with already scarce resources. (Sellers et al., 2005: 656)

The Victimization of PMI

Most research in the area of policing and PMI focuses on the illegal or violent behaviour of PMI ; that is, the PMI as offender or suspect. Considerably less is known about police interactions with mentally ill persons who have been the victims of crime. There is considerable evidence that PMI are victimized in the community (Teplin, 1985), often at rates much higher than those of the general population (Hiday et al., 1999; Silver, 2002a). Individuals with mental illness are also more likely to suffer repeated victimizations (Marley and Buila, 2001). Despite these high levels, the mentally ill often underreport their victimization experiences (Snowden and Lurigio, 2007). Reports of victimization by PMI have been found to be reliable (Goodman et al., 1999), but there is evidence that PMI are often disbelieved or discredited when reporting victimization (Mowbrary et al., 1998). The few studies available have consistently held that police officers are less willing to investigate and take action in cases where the victim is mentally ill (Finn and Stalans, 2002). Watson et al. (2004b) speculate that officers are less willing to act because mentally ill victims have less credibility in the eyes of the police.

A complex of social ills

Just as the police cannot solve the problem of PMI in isolation, mental illness itself must be considered in a broader context. In many cases, mental illness is but one element of a larger syndrome of problems an individual may be facing. These other problems greatly complicate the issue of mental illness for the police, and must necessarily be addressed as part of a comprehensive effort to improve encounters with PMI . Perhaps most importantly, it is impossible to divorce the issue of mental illness from that of poverty. Some 50 years ago, Hollingshead and Redlich confirmed "a significant relationship between social class and mental illness both in type and severity of mental illness suffered as well as in the nature and quality of treatment that is provided" (Pols, 2007). Their conclusion has consistently been supported (Greenblatt et al., 1967; Dohrenwend et al., 1992; Murali et al., 2004), and if anything the situation has further deteriorated; where the poor once received substandard treatment in institutions, they now often receive no treatment at all (Bassuk et al., 1984). In this literature, there remains a debate over the direction and mechanisms of causality. The social causation approach suggests that mental health problems are produced by the multiple stressors related to poverty, while the social drift perspective posits that poverty is the result of mental illness and its associated difficulties (Robbins et al., 2008). Both of these positions have empirical support, and the resolution of the debate is beyond this review. What is more important is the constellation of effects that intersect with both mental illness and poverty to raise the risk of contacts between PMI and the police.

One of the social difficulties connected to both mental illness and poverty is unemployment. There are several mechanisms that can lead to the low level of labour force participation characteristic of PMI . Some classificatory schemes are organized around time of onset. For example, the social underachievement thesis stipulates that joblessness is caused by the early onset of mental illness, which compromises educational attainment. Conversely, social decline refers to the loss of employment after the onset of mental health problems, which is then followed by sustained periods of unemployment and labour market re-entry difficulties (Nordt et al., 2007). More generally, the underemployment of PMI has been linked to unfavourable labour market dynamics, low productivity, a lack of appropriate vocational and clinical services, labour force discrimination, the failure of protective legislation, and work disincentives caused by state and federal policies (Cook, 2006). The negative consequences on personal finances are obvious, but joblessness is also deleterious to the extent that is deprives PMI of the social and psychological aspects of work, including social support and self-esteem.

The list of social difficulties for PMI further includes homelessness. Studies of jail and prison populations have consistently revealed a strong association between mental disorder and homelessness (Lamb and Weinberger, 1998; Michaels et al., 1992). Homelessness has been identified as an important pathway to incarceration among PMI (Lamb and Weinberger, 1998), while some surveys of PMI indicate that mental illness is the primary reason for becoming homeless (Susnick and Belcher, 1996). In a review of over 20 studies, Shlay and Rossi (1992) found that, on average, one third of homeless persons exhibited mental illness. A wide range of studies have similarly found high rates of homelessness among psychiatric patients. In Québec and Montréal, 36% of respondents reported being homeless at the time of their interview; nearly half (48%) had been homeless at some point (Bonin et al., 2007). In Toronto, two thirds of surveyed homeless persons reported a lifetime diagnosis of mental illness. In Ireland and Australia, the comparable figures were 13.8% (O'Neill et al., 2007) and 35% (White et al., 2006) respectively. As is the case with joblessness, mental illness and homelessness are mutually reinforcing. Homelessness complicates the treatment of mental illness, while mental illness increases the difficulty of exiting from homelessness.

Persons with mental illness similarly suffer from deficits of social relationships, social skills, and social support. Mentally ill persons, particularly those that are homeless, routinely report having very limited contact with family or close friends (White et al., 2006). Numerous studies have documented the protective effects of strong social support and the harmful consequences of poor social support (Ozbay et al., 2007). Social support plays a vital role not just simply in terms of instrumental considerations and material resources, but also in the construction of positive identities that allow patients to overcome the stigma of their status and aid in social integration into "mainstream life" (Forrester-Jones and Barnes, 2008). In terms of recovery, social support significantly increases the odds of enrolling and remaining in treatment programs. Conversely, the absence of such support reduces the likelihood of program compliance.

Another impediment for PMI is the increasingly frequent co-morbidity of physical illness. Serious mental disorders are frequently associated with a staggering array of serious physical health problems, including obesity, diabetes, cardiovascular disease (Muir-Cochrane, 2006), respiratory disease (Sánchez-Mora et al., 2007), head injuries, back problems, asthma, peptic ulcers, epilepsy, and cancer (Butler et al., 2007). As with the other complicating factors, there is a "chicken and egg" element to the link between mental illness and health problems; each may lead to the other, and both may arise from common antecedents (Dowrick, 2006). There is some evidence that the prevalence of risk factors such as cigarette smoking, sedentary lifestyle, and poor nutrition is elevated among people with mental illness (Leas and McCabe, 2007). The reciprocity between mental and physical illness inhibits efforts to address both. On one hand, "diagnostic overshadowing" describes situations where physical conditions are under-diagnosed and mistreated as the results of the misattribution of signs and symptoms of physical illness to concurrent mental disorders (Thornicroft et al., 2007). In contrast, physical illness inhibits treatment participation and retention, thereby decreasing its effectiveness (Gallagher et al., 2006).

A final, habitually problematic issue is that of "co-occurrence" or "dual diagnosis," referring to persons who simultaneously suffer from both mental illness and substance abuse. Epidemiological estimates consistently report that approximately half of all PMI have coexisting substance use disorders (Kessler, 2004). For these PMI , substance use creates multiple pathways into contact with the police, including:

[...] the commission of income-generating crimes, such as theft, burglary, and robbery to support the purchase of drugs; exacerbation of psychiatric symptoms leading to arrests for public nuisance offenses such as disturbing the peace; and the fact that the use of certain drugs, such as cocaine and heroin, is illegal and an offense in its own right. (Swartz and Lurigio, 2007: 582)

Simply put, there are pronounced differences between mentally ill offenders and offenders that are dually diagnosed. For PMI the concurrence of substance use increases the likelihood of police contacts (Borum et al., 1997) and arrest for any type of offence (Swartz and Lurigio, 2007), but perhaps the most disturbing aspect of co-occurring substance use for PMI is its link to heightened violence. While PMI are generally no more violent than persons without mental illness (Hiday, 1999), numerous studies have concluded that co-occurring substance use significantly increases the risk for involvement in violence (Mulvey, 1994; Swanson et al., 1996, 1999, 2002; Steadman et al., 1998; Swartz et al., 1998; Soyka, 2000). Compared to individuals with either mental illnesses or substance use disorders, dual diagnoses are characterized by increased probabilities of recidivism (Hartwell, 2004) as well as victimization (Sells et al., 2003).

Co-occurring conditions present substantial systemic response challenges. Coexisting conditions worsen the prognosis for both, as they tend to be characterized by higher relapse and symptom exacerbation rates, poor treatment outcomes, and less functional stability (Ziedonis and Stern, 2001). But despite the prevalence of concurrent disorders, there remains a "disturbing lack of resources for such individuals" (Wilson-Bases, 2008). The majority of treatment programs are designed to treat mental illness alone. These programs are not equipped for, and therefore will not admit, addicted PMI , leaving the police with few dispositional options. The police recognize that treatment is a much preferable avenue for these people, but it is simply unavailable.

Taken together, this complex of social ills coalesces to greatly increase the odds of PMI coming into contact with the police. With few financial resources and attenuated social support networks, many PMI find themselves living on the streets. Because they are homeless, their behaviour is more likely to be public and, by extension, more likely to prompt contact with the police. The multiplicity of conditions increases the likelihood that treatment regimes will not be adhered to and reduces the effectiveness of treatment programs, leading to deteriorating mental health and, again, contact with the police. The co-occurrence of substance abuse raises the potential for violence. In sum, mental illness is but one facet of a broader syndrome of mutually-reinforcing risk factors. At the same time, the complexities associated with mental illness underscore the difficulties facing the police in their interactions with PMI .

Coming full circle: Where does responsibility reside?

As noted in the introduction, there is little doubt that dealing with persons with mental illness falls under the purview of the police, charged as they are both with protecting public safety and protecting members of the community who may not be able to fend for themselves. There is some evidence from attitudinal surveys that police officers themselves recognize a responsibility for dealing with the mentally ill (Cooper et al., 2004). At the same time, there is a real sense that the distribution of responsibility for PMI increasingly is inequitable. From this perspective, the question is not "Who has the responsibility for PMI ?" but rather "What proportion of responsibility should reasonably be allocated to the police?" When a police chief such as Bernard Parks comments that the "police should not have to handle so many mentally ill people on the streets," it is not an abdication of responsibility so much as a statement of frustration. On balance the police feel ill-equipped to deal with PMI . Moreover, the increasing number of contacts with PMI is acting as a drain on already depleted police resources. Caught in the historical currents of deinstitutionalization, the police are too often called upon as the institution of last resort. Mental illness is incredibly complex, bound up as it is with a number of other serious social maladies over which the police have little or no control. To the degree that mental illness is symptomatic of concurrent poverty, joblessness, homelessness, social exclusion, health problems and addiction, there would appear to be abundant responsibility to go around.

Summary

1. Most of the literature pertaining to police contacts with PMI suggests that such interactions are increasingly common.
2. A number of reasons have been advanced to account for this increased contact, including: the effects of deinstitutionalization and changes to civil commitment laws; the lack of resources afforded to community corrections; the inadequacy of related social services; neighbourhood concentration effects; the philosophical shift to community policing; and a contraction of community tolerance for aberrant behaviour.
3. Despite the perception (and anecdotal evidence) that police contacts with PMI are on the rise, there is little empirical support for this contention. There is a paucity of important baseline data from which to draw sound conclusions about the incidence of and prevalence of police-PMI interactions.
4. There is also limited information regarding the specific types of behaviours that bring PMI into contact with the police, as well as the outcomes of these interactions.
5. Because many police contacts with PMI appear to be of a relatively minor nature, the police often have wide discretion in disposing of these cases. The actual exercise of discretion generally has been found to be contingent upon a number of considerations, including contextual factors, situational variables, and the characteristics of both the police officer(s) and the offender/victim/witness. However, research on the exercise of discretion specifically in cases involving PMI is scant.
6. Although relatively rare, the use of force against PMI often generates negative publicity and is of paramount concern both to police officers and departments. As with the remarks on discretion, there is sparse information on the use of force in the context of interactions with PMI .
7. Many police organizations have not established clear guidelines and protocols for dealing with PMI .
8. Because many police officers receive insufficient training on issues related to the mentally ill population, increased training is among the most commonly cited mechanism for improving contacts with PMI . It is similarly important, however, to be cautious of invoking training as a panacea; the wrong sort of training can appreciably worsen interactions.
9. Given the complexity of mental illness and the range of concurrent conditions, comprehensive responses to PMI require collaborative efforts. At the same time, current relations between the police and the mental health system are in many instances strained, and interagency cooperation will have to overcome mutual distrust.
10. A number of jurisdictions have implemented specialized programs to try to improve police contacts with PMI . The efficacy of these programs is still the subject of some debate. Perceptions of the utility of these programs seem to be bound up in broader ideological debates over whether policing is more appropriately generalist or specialist.
11. While the bulk of attention in this area is focused on PMI as "offenders," it is important to note that these people are also at greater risk of victimization.
12. Coming to grips with the issues highlighted in this report requires a holistic understanding of mental illness as one aspect of what has been termed here "a complex of social ills," a syndrome of disadvantage that also implicates poverty, joblessness, homelessness, social exclusion, generalized health concerns, and substance abuse.

References

Abramson, M. (1972). The criminalization of mentally disordered behavior: Possible side effects of a new mental health law. Hospital and Community Psychiatry,23,101-105.

Bachrach, L. (1982). Young adult chronic patients: An analytical review of the literature. Hospital and Community Psychiatry, 33(2), 189-196.

Bassuk, E. L., L. Rubin, and A. Lauriat (1984). Is homelessness a mental health problem? American Journal of Psychiatry, 141, 2546-2550.

Bittner, E. (1967). Police Discretion in Emergency Apprehension of Mentally Ill Persons, Social Problems, 14, 278-292.

Bonin, J.-P., L. Fournier, and R. Blais (2007). Predictors of mental health service utilization by people using resources for homeless people in Canada. Psychiatric Services, 58(7), 936-941.

Bonovitz, J. C. and J. S. Bonovitz (1981). Diversion of the mentally ill into the criminal justice system: The police intervention perspective. American Journal of Psychiatry,138(7), 973-976.

Borum, R. (2000). Improving high risk encounters between people with mental illness and the police. Journal of the American Academy of Psychiatry and the Law,28(3), 332-337.

Borum, R., M. W. Deane, H. J. Steadman, and J. Morrissey (1998). Police perspectives on responding to mentally ill people in crisis: Perceptions of program effectiveness. Behavioral Sciences and the Law,16, 393-405.

Borum, R., J. Swanson, M. Swartz, and V. Hiday (1997). Substance Abuse, Violent Behavior, and Police Encounters among Persons with Severe Mental Disorder. Journal of Contemporary Criminal Justice, 13(3), 236-250.

Butler, T., S. Allnutt, and B. Yang (2007). Mentally ill prisoners in Australia have poor physical health.  International Journal of Prisoner Health, 3(2), 99-110.

Cook, J. A. (2006). Employment barriers for persons with psychiatric disabilities: Update of a report for the President's Commission. Psychiatric Services, 57(10), 1391-1405.

Cooper, V. G., A. M. Mclearen, and P.A. Zapf (2004). Dispositional decisions with the mentally ill: Police perceptions and characteristics. Police Quarterly, 7(3), 295-310.

Cordner, G. W. (2000). A community policing approach to persons will mental illness. Journal of the American Academy of Psychiatry and the Law, 28, 326-331.

Cotton, D. (2004). The attitudes of Canadian police officers toward the mentally ill. International Journal of Law and Psychiatry, 27, 35-146.

Cotton, D., and K. Zanibbi (2003). Police officers' knowledge about mental illness. Canadian Journal of Police and Security Studies,1(2), 136-143.

Crawford, C. and R. Burns (1998). Predictors of the police use of force: The application of a continuum perspective in Phoenix. Police Quarterly, 1, 41-63.

Cumming E., I. Cumming, and L. Edell (1965). Policeman as philosopher, guide, and friend. Social Problems, 12, 276-286.

Deane, M. W., H. J. Steadman, R. Borum, B. M. Veysey, and J. P. Morrissey (1999). Emerging partnerships between mental health and law enforcement. Psychiatric Services,50(1), 99-101.

Dohrenwend, B. P., I. Levav, P. E. Shrout, et al. (1992). Socioeconomic status and psychiatric disorders: The causation-selection issue. Science, 255, 946-952.

Dowrick C. (2006). Chickens and eggs: Examining the links between mental health and chronic disease. International Journal of Psychiatry in Medicine, 36(3), 263-67.

Dupont, R. and S. Cochran (2000). Police response to mental health emergencies  – barriers to change. Journal of the American Academy of Psychiatry and the Law,28(3) 338-344.

Engel, R. S., and E. Silver (2001). Policing mentally-disordered suspects: A re-examination of the criminalization hypothesis. Criminology, 39, 225-252.

Engel, R. S., J. J. Sobol, and R. E. Worden (2000). Further exploration of the demeanor hypothesis: The interaction effects of suspects' characteristics and demeanor on police behavior. Justice Quarterly, 17, 236-258.

Finn, M. A., and L. J. Stalans (2002). Police handling of the mentally ill in domestic violence situations. Criminal Justice and Behavior,29(3), 278-307.

Finn, P. and M. Sullivan (1989). Police handling of the persons with mental illnesses: Sharing responsibility with the mental health system. Journal of Criminal Justice, 17, 1-14.

Forrester-Jones, R., and A. Barnes (2008). On being a girlfriend not a patient: The quest for an acceptable identity amongst people diagnosed with a severe mental illness.Journal of Mental Health, 17(2), 153-172.

Freidrich, R. J. (1980). Police use of force: Individuals, situations and organizations. Annals of the American Academy of Political and Social Science, 452, 87-97.

Fry, A. J., D. P. O'Riordan, and R. Geanellos (2002). Social control agents or front-line carers for people with mental health problems: Police and mental health services in Sydney, Australia. Health and Social Care in the Community, 10(4), 277-286.

Fyfe, J. J. (2000). Policing the emotionally disturbed. Journal of the American Academy of Psychiatry and the Law,28(3), 345-47.

Gallagher, S. M., A. J. Brooks, and P. E. Penn (2006). Chronic illness, pain and health behaviors of community behavioral health clients. Psychological Services, 3(4), 215-226.

Garner, J. H., and C. D. Maxwell (2002). Understanding the use of force by and against the police in six jurisdictions (NCJ Report No. 196694). Washington, DC: National Institute of Justice.

Gillig, P. M., M. Dumaine, J. W. Stammer, J. R. Hillard, and P. Grubb (1990). What do police officers really want from the mental health system? Hospital and Community Psychiatry, 41(6), 663-65.

Gillon, S. M. (2000). "That's not what we meant to do": Reform and its unintended consequences in twentieth-century America. New York: W. W. Norton.

Gilston, D. H., and L. Podell (1959). The Practical Patrolman. Springfield, IL: Charles C. Thomas.

Godschalx, S. M. (1984). Effect of a mental health educational program upon police officers. Research in Nursing and Health,7, 111-17.

Goldstein, H. (1977). Policing in a Free Society. Baltimore: Johns Hopkins University Press.

Goodman, L., K. Thompson, K. Weinfurt, S. Corl, P. Acker, K. Mueser, et al. (1999). Reliability of reports of violent victimization and posttraumatic stress disorder among men and women with serious mental illness. Journal of Traumatic Stress, 14, 587-599.

Green, T. M. (1997). Police as frontline mental health workers: The decision to arrest or refer to mental health agencies. International Journal of Law and Psychiatry, 20, 469-486.

Greenblatt, M., P. E. Emery, and B.C. Glueck (1967). Poverty and Mental Health. Washington, DC: American Psychiatric Association.

Hails, J. and R. Borum (2003). Police training and specialized approaches to respond to people with mental illnesses. Crime and Delinquency,49(1), 52-61.

Hanewicz, W. B., L. M. Fransway, and M. W. O'Neill (1982). Improving the linkages between community mental health and the police. Journal of Police Science and Administration, 10(2), 218-223.

Hartwell, S. (2004). Triple Stigma: Persons With Mental Illness and Substance Abuse Problems in the Criminal Justice System. Criminal Justice Policy Review, 15(1), 84-99.

Hiday, V.A., M. S. Swartz, J. W. Swanson, R. Borum, and H. R. Wagner (1999). Criminal victimization of persons with severe mental illness. Psychiatric Services, 50, 62-68.

Hiday, V.A. (1999). Mental illness and the criminal justice system. In A. V. Horowitz and T. L. Scheid (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems. New York: Cambridge University Press, 508-525.

Hill, R. and J. Logan (2001). Civil liability and mental illness: A proactive model to mitigate claims. The Police Chief, June, 29-32.

Husted J. R., R. A. Charter, and B. Perrou (1995). California law enforcement agencies and the mentally ill offender. Bulletin of the American Academy of Psychiatry and the Law, 23, 315-329.

Janus, S., B. Bess, J. Cadden, and H. Greenwald (1980). Training police officers to distinguish mental illness. American Journal of Psychiatry, 137, 228-29.

Kalinich, D. B. and J. D. Senese (1987). Police discretion and the mentally disordered in Chicago: A reconsideration. Police Studies, 10, 185-191.

Kaminski, R. J., C. DiGiovanni, and R. Downs (2004). The use of force between the police and persons with impaired judgment. Police Quarterly, 7(3), 311-338.

Kessler, R. C. (2004). The epidemiology of dual diagnosis. Biological Psychiatry,56,730-37.

Kupers, T. A. (1999). Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do about It. San Francisco, CA: Jossey-Bass.

LaGrange, T. C. (2003). The role of police education in handling cases of mental disorder. Criminal Justice Review,28(1), 88-112.

Lamb, H. R. (1982). Treating the Long-Term Mentally Ill. San Francisco: Jossey-Bass.

Lamb, H. R. and L. E. Weinberger (1998). Persons with severe mental illness in jails and prisons: A review. Psychiatric Services, 49(4), 483-392.

Lamb, H. R., L. E. Weinberger, and W. J. DeCuir (2002). The police and mental health. Psychiatric Services,53(10), 1266-1271.

Leas, L., and M. McCabe (2007). Health behaviors among individuals with schizophrenia and depression. Journal of Health Psychology, 12(4), 563-579.

Lester, D. and C. Pickett (1978). Attitudes toward mental illness in police officers. Psychological Reports, 42, 888.

Lewis, D. A., S. Riger, H. Rosenberg, H. Wagenaar, A. J. Lurigio, and S. Reed (1991). Worlds of the mentally ill: How deinstitutionalization works in the city. Carbondale, IL: Southern Illinois University Press.

Link, B. G., H. Andrews, and F. T. Cullen (1992). The violent and illegal behavior of mental patients reconsidered. American Sociological Review, 57, 275-292.

Lurigio, A. J. (2000). Persons with serious mental illness in the criminal justice system: Background, prevalence, and principles of care. Criminal Justice Policy Review,11(4), 312-328.

Manning, P. (1984). Police classification and the mentally ill. In L. Teplin (Ed.), Mental Health and Criminal Justice (177-198), Beverly Hills, CA: Sage Publications.

Markowitz, F. E. (2006). Psychiatric hospital capacity, homelessness, and crime and arrest rates. Criminology, 44(1), 45-72.

Marley, J. A., and S. Buila (2001). Crimes against people with mental illness: Types, perpetrators, and influencing factors. Social Work,46(2), 115-124.

Matthews, R.A., and L. Rowland (1960). How to recognize and handle abnormal people: a manual for the police officer. Arlington, VA: National Association for Mental Health.

Menzies, R. J. (1987). Psychiatrists in blue: Police apprehension of mental disorder and dangerousness. Criminology, 25, 429-452.

Micheals, D., S. R. Zoloth, and P. Alcabes (1992). Homelessness and indicators of mental illness among inmates in New York City's correctional system. Hospital and Community Psychiatry, 43(2), 150-54.

Mowbrary, C., D. Oyserman, D. Saunders, and A. Rueda-Riedle (1998). Women with severe mental disorders: Issues and service needs. In B. Levin and A. Blanch (Eds.), Women's Mental Health Services: A Public Health Perspective. Thousand Oaks, CA: Sage Publications. 175-200.

Muir-Cochrane, E. (2006). Medical co-morbidity risk factors and barriers to care for people with schizophrenia. Journal of Psychiatric and Mental Health Nursing, 13(4), 447-452.

Mulvey, E. (1994). Assessing the evidence of a link between mental illness and violence. Hospital and Community Psychiatry,45, 663-68.

Murali, V. and F. Oyebode (2004). Poverty, social inequality and mental health. Advances in Psychiatric Treatment, 10, 216-224.

Murphy, G. R. (1986). Special Care: Improving the Police Response to the Mentally Disabled. Washington, DC: Police Executive Research Forum.

Nordt, C., B. Müller, W. Rössler, and C. Lauber (2007). Predictors and course of vocational status, income, and quality of life in people with severe mental illness: A naturalistic study. Social Science & Medicine, 65(7), 1420-29.

Novak, K. J., and R. S. Engel. (2005). Disentangling the influence of suspects' demeanor and mental disorder on arrest. Policing: An International Journal of Police Strategies & Management, 28(3), 493-512.

Olivero, J. M. (1990). Police linkage with community mental health centers in the management of criminal justice-mental health. Journal of Police and Criminal Psychology, 6, 8-13.

O'Neill, A., P. Casey, and R. Minton (2007). The homeless mentally ill: An audit from an inner city hospital. Irish Journal of Psychological Medicine, 24(2), 62-66.

Ozbay, F., D. C. Johnson, E. Dimoulas, C. A. Morgan III, D. Charney, and S. Southwick (2007). Social support and resilience to stress: From neurobiology to clinical practice. Psychiatry, 4(5), 35-40.

Panzarella, R. and J. O. Alicea (1997). Police tactics in incidents with mentally disturbed persons. Policing: An International Journal of Police Strategies & Management, 20(2), 326-338.

Patch, P.C. and B. A. Arrigo (1999). Police officer attitudes and use of discretion in situations involving the mentally ill: The need to narrow the focus. International Journal of Law and Psychiatry, 22(1), 23-35.

Perkins, E. B., G. W. Cordner, and K. E. Scarborough (1999). Police handling of people with mental illness. In L. K. Gaines and G. W. Cordner (Eds.), Policing Perspectives: An Anthology. Los Angeles, CA:,Roxbury. 289-297.

Phelan, J. and B. Link (1998). The growing belief that people with mental illnesses are violent: The role of the dangerousness criterion for civil commitment. Social Psychiatry, 33, S7-S12.

Pogrebin, M. R. (1986). Police responses for mental health assistance. Psychiatric Quarterly, 58(1), 66-73.

Pols, H. (2007). August Hollingshead and Frederick Redlich: Poverty, socioeconomic status, and mental illness. American Journal of Public Health, 97(10), 1755.

Robbins, V., N. Dollard, B. J. Armstrong, K. Kutash, and K. S. Vergon (2008). Mental health needs of poor suburban and rural children and their families. Journal of Loss & Trauma, 13(2-3), 94-122.

Rogers, A. (1990). Policing mental disorders: Controversies, myths and realities. Social Policy & Administration, 24(3), 226-236.

Ruiz, J. and C. Miller (2004). An exploratory study of Pennsylvania police officers' perceptions of dangerousness and their ability to manage persons with mental illness. Police Quarterly, 7(3), 359-371.

Sánchez-Mora, N., Ó Medina, B. Francisconi, N. W. Meza, N. Rossi, F. Colmenares, M. P. Redondo, and C. Arango (2007). Risk factors for respiratory disease in chronic psychiatric inpatients. European Journal of Psychiatry, 21(3), 212-19.

Scott, R. L. (2000). Evaluation of a mobile crisis program: Effectiveness, efficiency, and consumer satisfaction. Psychiatric Services, 51(9), 1153-1156.

Sellers, C. L., C. J. Sullivan, B. M. Veysey, and J. M. Shane (2005). Responding to persons with mental illnesses: Police perspectives on specialized and traditional practices. Behavioral Sciences & the Law,23, 647-657.

Sells, D. J., M. Rowe, and D. Fisk (2003). Violent victimization of persons with co-occurring psychiatric and substance use disorders. Psychiatric Services, 54(9), 1253-1257.

Shlay, A. B. and P. H. Rossi (1992). Social science research and contemporary studies of homelessness. Annual Review of Sociology, 18, 129-160.

Silver, E. (2000a). Extending social disorganization theory: A multilevel approach to the study of violence among persons with mental illnesses. Criminology,38, 301-332.

Silver, E. (2000b). Race, neighborhood disadvantage, and violence among persons with mental disorders: The importance of contextual measurement. Law and Human Behavior,24, 449-456.

Snowdon, J. and A. J. Lurigio (2007). The mentally ill as victims of crime. In R. C. Davis, A. J. Lurigio, and S. Herman (Eds.), Victims of Crime (3rd Ed.). Thousand Oaks, CA: Sage Publications. 189-199.

Soyka, M. (2000). Substance misuse, psychiatric disorder and violent and disturbed behaviour. British Journal of Psychiatry,176, 345-350.

Stadish, W. R. (1989). Private sector care for chronically mentally ill individuals: The more things change, the more the same. American Psychologist, 44, 1142-47.

Steadman, H. J. (1992). Boundary spanners: A key component for the effective interactions of the justice and mental health systems. Law and Human Behavior, 16(1), 75-87.

Steadman, H. J., E. P. Mulvey, J. Monahan, P. C. Robbins, P. S. Applebaum, and T. Grisso (1998). Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General Psychiatry, 55, 393-401.

Stefan, S. (1996). Issues relating to women and ethnic minorities in mental health treatment and law. In B. D. Sales and D.W. Shuman (Eds.), Law, mental health, and mental disorder. Pacific Grove, CA: Brooks/Cole. 240-278.

Susnick, L. C. and J. R. Belcher (1996). Why are the homeless? The chronically mentally ill in Washington, DC. International Journal of Mental Health, 24(4), 70-84.

Swanson, J., R. Borum, and M. Swartz (1996). Psychotic symptoms and disorders and the risk of violent behavior in the community. Criminal Behavior and Mental Health, 6, 317-338.

Swanson, J., R. Borum, M. Swartz, and V. Hiday (1999). Violent behavior proceeding hospitalization among persons with severe mental illness. Law and Human Behavior, 23(2), 185-204.

Swanson, J. W., C. E. Holzer III, V. K. Ganju, and R. T. Jono (1990). Violence and psychiatric disorder in the community: Evidence from the epidemiological catchment area surveys. Hospital and Community Psychiatry, 1, 761-770.

Swanson, J. W., M. S. Swartz, S. M. Essock, F. C. Osher, H. R. Wagner, L. A. Goodman, S. D. Rosenberg, and K. G. Meador (2002). The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health, 92(9), 1523-1531.

Swartz, J. A. and A. J. Lurigio (2007). Serious mental illness and arrest: The generalized mediating effect of substance use. Crime and Delinquency, 53(4), 581-604.

Swartz, M. S., J. W. Swanson, V. A. Hiday, R. Borum, H. R. Wagner, and B. J. Burns (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226-231.

Teller, J. L. S., M. R. Munetz, K. M. Gil, and C. Ritter. (2006). Crisis intervention team training for police officers responding to mental disturbance calls. Psychiatric Services,57(2) 232-37.

Teplin, L. A. (1984a). Managing disorder: Police handling of the mentally ill. In L. A. Teplin (Ed.), Mental Health and Criminal Justice (157-176). Beverly Hills, CA: Sage Publications.

Teplin, L. A. (1984b). Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist,39, 794-803.

Teplin, L.A.(1985). The Criminality of the Mentally Ill: A Dangerous Misconception. American Journal of Psychiatry,142, 593-99.

Teplin, Linda A. and N. S. Pruett (1992). Police as streetcorner psychiatrists: Managing the mentally ill. International Journal of Law and Psychiatry,15, 139 –156.

Terrill, W. and S. D. Mastrofski (2002). Situational and officer-based determinants of police coercion. Justice Quarterly, 19, 215-248.

Thornicroft, G., D. Rose, and A. Kassam (2007). Discrimination in health care against people with mental illness. International Review of Psychiatry, 19(2), 113-122.

Trovato, F. (2000). Community policing and the emotionally disturbed persons (EDP's): Are we meeting their needs. Unpublished master's thesis. New York: Niagara University.

Vermette, H. S., D. A. Pinals, and P. S. Appelbaum (2005). Mental health training for law enforcement professionals. Journal of the American Academy of Psychiatry and the Law,33(1) 42-46.

Watson, A. C., P. W. Corrigan, and V. Ottati (2004a). Police officers' attitudes toward and decisions about persons with mental illness. Psychiatric Services,55(1), 49-53.

Watson, A. C., P. W. Corrigan, and V. Ottati (2004b). Police responses to persons with mental illness: Does the label matter? Journal of the American Academy of Psychiatry and the Law, 32, 378-385.

Wells, W. and J. A. Schafer (2006). Perceptions of police responses to persons with mental illness. Policing: An International Journal of Police Strategies & Management, 29(4), 578-601.

White, P., D. Chant, and H. Whiteford (2006). A comparison of Australian men with psychotic disorders remanded for criminal offences and a community group of psychotic men who have not offended. Australian and New Zealand Journal of Psychiatry, 40(3), 260-65.

Wilson, J. Q. and G. L. Kelling. (1982). The police and neighborhood. The Atlantic, March, 29-38.

Wilson-Bates, F. (2008). Lost in Transition: How a Lack of Capacity in the Mental Health System is Failing Vancouver's Mentally Ill and Draining Police Resources. Report prepared for the Vancouver Police Department.

Wolff, N. (1998). Interactions between mental health and law enforcement systems: Problems and prospects for cooperation. Journal of Health Politics, 23(1), 133-174.

Wolff, N., R. J. Diamond, and T. W. Helminiak (1997). A new look at an old issue: People with mental illness and the law enforcement system. The Journal of Mental Health Administration, 24(2), 152-165.

Worden, R. (1995). The causes of police brutality: Theory and evidence on police use of force. In W. Geller and H. Toch (Eds.), And justice for all: Understanding and controlling police abuse of force (31-60). Washington, DC: Police Executive Research Forum.

Ziedonis, D. M. and R. Stern (2001). Dual recovery therapy for schizophrenia and substance abuse. Psychiatric Annals, 31(4), 255-264.