POSSIBLE INDICATORS OF MENTAL ILLNESS
- Sharing a combination of unrelated or abstract topics
- Expressing thoughts of greatness
- Indicating ideas of being harassed or threatened
- Exhibiting a preoccupation with death, germs, guilt, or other similar ideas
Unusual speech patterns
- Nonsensical speech or chatter
- Word repetition
- Pressured speech
- Extremely slow speaking
Verbal hostility or excitement
- Talking excitedly or loudly
- Being argumentative, belligerent, or unreasonably hostile
- Threatening harm to self or others
- Inappropriate to environment
- Bizarre clothing or makeup (taking into account current trends)
- Strange postures or mannerisms
- Lethargic, sluggish movements
- Pacing, agitation
- Repetitive, ritualistic movements
Seeing, smelling, or hearing things that cannot be confirmed
Confusion about or unawareness of surroundings
Lack of emotional response
Causing injury to self
Nonverbal expressions of sadness or grief
Inappropriate emotional reactions
- Overreacting to situations in an overly angry or frightening way
- Reacting with the opposite of expected emotion
- Strange trimmings, misuse of household items
- “Packratting” – accumulation of trash
- Presence of feces or urine on the floor or walls
Source: Georgia Association of Chiefs of Police Mental Health Ad Hoc Committee to Address Mental Health Issues in Law Enforcement, Mental Health and Law Enforcement Encounters: A Review of Current Problem and Recommendations, http://www.gachiefs.com/pdfs/NEWS_GACP%20Mental%20Health%20Report.pdf (accessed August 15, 2013), pages R-4 – R-6.
A variety of disorders drastically can affect a person’s logic and behaviors.
Law enforcement officers and other public safety workers commonly interact with people suffering from a mental disorder—defined as a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning…. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.” The cause of the unusual behavioral or psychological pattern cannot solely be “an expectable or culturally approved response to a common stressor or loss,” nor can a behavior be deemed a mental disorder simply because it violates society’s norms and values.
A variety of disorders drastically can affect a person’s logic and behaviors. The Diagnostic and Statistical Manual of Mental Disorders: DSM-5 widely is used and accepted in the classification and definition of various mental disorders. The DSM-5 provides diagnostic criteria for recognized mental disorders, although these do not dictate or supplant a clinician’s professional judgment. In addition, the manual contains extensive descriptive and empirical data about each disorder.
The DSM-5 diagnostic criteria are complex and require careful training to apply. For instance, the criteria for schizophrenia include the presence of symptoms over a 6-month time period, including at least one of the following behaviors in the course of a month: “Delusions, hallucinations, [or] disorganized speech (e.g., frequent derailment or incoherence). In addition, at least one other criterion must be present over the course of a month, whether another of those listed above or grossly disorganized or catatonic behavior, and negative symptoms” (such as showing the inability to follow through on projects, demonstrating flattened emotions, or exhibiting inadequate communication). In addition, clinicians must consider the relationship of the symptoms to other potential diagnoses, rule out the effects of drug or other medical conditions as a cause of the symptoms, and limit diagnoses to those cases in which individuals have experienced impairment in a major life activity.
The National Institute of Mental Health (NIMH) estimates that 1 in every 4 adults suffers from some form of a measurable mental disorder. NIMH also suggests that nearly 6 percent of the U.S. population suffers from a severe mental disorder.
A 2009 study found that individuals with mental health disorders no more likely will commit acts of violence than the rest of the population; rather, future violence was indicated by other factors, such as substance abuse and a prior history of such acts. One explanation is that some individuals with severe disorders are too disorganized or afraid to commit crimes. For example, individuals with severe schizophrenia may have delusions—for instance, a belief that they and others around them face a danger of attack or threat. This leads some persons suffering from this form of delusion to seclude themselves from the outside world and to express extreme caution toward others.
Many persons in society stigmatize mental health disorders, which leads to additional discrimination and prejudice against persons with such conditions. An individual with an untreated mental disorder may be seen as having criminal intentions. In many cases, persons with mental disorders are arrested “not because they are more dangerous or malicious than other individuals, but because they have unmet needs.”
Treatment and control of mental disorders can prove costly. Often, people who suffer from these illnesses find it difficult to maintain employment and to have access to adequate health insurance. To this end, through medicine, pharmacological treatment, and psychological resources, such as cognitive behavioral therapy, many symptoms can be treated and alleviated. However, without proper attention, symptoms may worsen and lead to behaviors that bring these individuals into frequent contact with the criminal justice system. The subjects may not purposely participate in illicit acts, but resiliency and survival techniques may cause them to partake in deviant behavior. For instance, mental illness is a significant cause of homelessness, which, in turn, can lead to arrests for trespassing or loitering when homeless persons set up living quarters on private property or in public areas.
The deinstitutionalization of mental health centers that occurred in the latter half of the 20th century, coupled with inadequate funding for many mental-health treatment programs, left police officers with less options to work with when dealing with individuals struggling with mental disorders. Fewer locations exist where law enforcement personnel can escort these persons, and, due to funding restrictions, the individuals are expected to pay for their own mental health care. Often, they cannot afford or simply do not have medical insurance. When treatment options are not available, rather than taking a person with mental illness to jail, officers may transport the individual to a hospital facility, particularly when they believe the person may pose a risk to themselves or others.
Contact with Corrections Officers
Many persons in society stigmatize mental health disorders, which leads to additional discrimination and prejudice against persons with such conditions.
At some point in the course of their work, virtually all criminal justice personnel will interact with individuals struggling with mental disorders. Particularly, state prison officials work with populations diagnosed with such illnesses at a rate far greater than that of the general public. Individuals with mental disorders are highly overrepresented within jails and prisons across the nation, even though they pose no more likelihood to commit serious crimes than anyone else. Although approximately one-quarter of American adults suffer from some type of mental disorder, in 2005 approximately 56 percent of state prison inmates had at least one form of a mental illness. Of the state prisoners, 43 percent reported symptoms that met the standards for classification as mania, 23 percent presented symptoms tied to major depression, and 15 percent had some type of a psychotic disorder.
To more appropriately manage a large population of persons with mental illness, many local jails have adopted and used a brief-jail-mental-health-screening (BJMHS) checklist. Screenings need to quickly identify mental health risks due to the large volume of inmates a facility might receive. Questions on a BJMHS may include: “Do you currently feel like you have to talk or move more slowly than you usually do?” or “Do you currently feel that other people know your thoughts and can read your mind?”
BJMHS checklists have proven effective as screening tools. Studies evaluating their effectiveness in Maryland and New York jails have shown them to be accurate in identifying mental health issues. A BJMHS typically takes only 2 to 3 minutes to complete. One study compared BJMHS results with those from the more extensive Structured Clinical Interview for DSM-IV, a mental health diagnostic instrument. On that basis, the study found that one BJMHS correctly classified 80 percent of males and 72 percent of females and that it referred 16 percent of subjects for further mental health assessment based on the screening results. A BJMHS is practical, quick, and efficient and easily could be adapted for use in other fields of the criminal justice system, such as law enforcement.
Interacting with Persons with Mental Illnesses
- Collect as much information as possible from all possible sources prior to intervening.
- Take your time and eliminate noise and distractions.
- Ask permission first.
- Treat them with dignity and respect as you would a family member.
- Keep your distance and respect personal space.
- Talk slowly and quietly. Identify yourself and others and explain your intentions/actions. Your actions should be slow, and prior warning should be given if you intend on moving about the room.
- Explain in a firm, but gentle, voice that you want to help. Ask how you can be of assistance.
- Develop a sense of working together: “Help me to understand what is happening to you.”
- If they are fearful of your equipment, take the time to explain that you carry the equipment to enable you to perform your job, which is to protect the public and them.
- Give choices whenever possible to allow some level of control.
- Deceive—be honest and open in all situations. You are reality.
- Tease or belittle.
- Forget the pain and fear they are experiencing. Remember that emotions can be painful.
- Violate personal space.
- Forget to ask about medications used.
Source: Ron Hoffman and Laurel Putnam, Not Just Another Call: Police Response to People with Mental Illnesses in Ontario: A Practical Guide for the Frontline Officer (Sudbury, CA: Centre for Addiction and Mental Health, 2004); 10.
Interactions with Law Enforcement Personnel
At some point in the course of their work, virtually all criminal justice personnel will interact with individuals struggling with mental disorders.
As police officers often come in contact with individuals with mental disorders, departments located within U.S. cities featuring populations of greater than 100,000 reported that approximately 7 percent of officer interactions involved persons with mental illness. For instance, in 2000 Florida law enforcement personnel transported more than 40,000 people with various mental disorders for psychiatric evaluation and treatment.
Many agencies have adopted a Crisis Intervention Team (CIT) model, which stresses the importance of a partnership between law enforcement personnel and mental health professionals. Through such partnerships, officers receive training to better understand certain situations involving individuals with mental disorders, including how to appropriately control confrontations. The Commission on Accreditation for Law Enforcement Agencies (CALEA) recommends that departments have in place plans and practices for working with mentally ill persons. CIT training programs typically involve approximately 40 hours of intensive classroom and practical instruction for law enforcement officers to become certified in the CIT program. The training teaches them to react to mental health scenarios more empathetically, compassionately, and effectively. It emphasizes skills that help officers de-escalate situations involving persons with mental disorders while focusing on public and officer safety. Refresher courses often are available for participating agencies, but at the time of this writing, there is no recertification process for the CIT program.
Widely adopted nationwide, CIT training and certification processes help to promote consistency between agencies while also allowing individual departments to tailor their CIT programs to best fit their needs. The Roanoke County Police Department, one of the first to implement CIT training in Southwestern Virginia, provides one example of how a CIT program may be structured. According to one of the leading coordinators with the CIT program, roughly half of their 140 police officers are certified in CIT methods. There always is at least one CIT-trained officer available during each shift. Although not required, the department tries to encourage all patrol officers to participate in the training. Police recruits receive various CIT training blocks throughout their academy instruction, although this training does not meet all standards necessary for certification.
The Roanoke County Police Department participates in an annual, weeklong CIT training course sponsored by Mental Health America (MHA), which provides various speakers and professionals from mental health arenas who offer seminars to police officers. The training also includes on-site visits to local rehabilitation centers and hospitals. Officers participate in role-playing scenarios and other hands-on training.
When working with persons with mental disorders, the Roanoke County Police Department uses a three-prong test to ascertain 1) whether individuals pose a danger to themselves, 2) if a person endangers others, or 3) whether individuals cannot care for themselves. If a person meets any of these criteria, the officer will take the individual into emergency custody. As noted in section 37.2-808 of the Code of Virginia, “A law enforcement officer who, based upon his observation or the reliable reports of others, has probable cause to believe that a person meets the criteria for emergency custody…may take that person into custody and transport that person to an appropriate location to assess the need for hospitalization or treatment without prior authorization.” The person then will be transported to an emergency medical facility where an emergency outreach service (EOS) worker further evaluates the individual. After the evaluation, if the EOS worker deems the individual to be at risk or a threat, a temporary detention order (TDO) may be placed on the person, and the individual will be held in a mental health facility pending further evaluation.
Transition of a Checklist into Law Enforcement Use
While a mental health screening tool and accompanying resources offer many benefits, agencies must acknowledge the potential limitations.
Criminal justice professionals have discovered that in many instances, while not necessarily violent, crime (intentional or not) and mental disorders go hand-in-hand. The CIT model and the three-part test employed by the Roanoke County Police Department provide a useful approach to working with persons with mental disorders. However, agencies must consider additional effective and efficient means for addressing issues related to such persons. Mental-health-screening checklists currently are in use in correctional settings and have proven effective both in classifying and determining possible security placements and treatments. This suggests the possibility of developing a similar mental-health checklist for use by law enforcement.
Similar to a BJMHS, a checklist for law enforcement officers should easily be usable in a field setting. Law enforcement personnel must use the checklist to make a quick and accurate assessment. A sample policy prepared by the Georgia Association of Chiefs of Police (GACP) noted the importance of observing “verbal, behavioral, and environmental cues” interpreted through “the context of the situation” while being “mindful of environmental and cultural factors.” One challenge inherent in the construction of a checklist encompassing these factors is that police officers need a checklist brief enough for practical use in the field, but descriptive enough to accurately assess the situation. The checklist in table 1 was presented in a resource guide prepared by the GACP Mental Health Ad-Hoc Committee and could be adapted for field use by police officers.
Such a checklist should be used holistically, rather than in treating one specific cue as dispositive. Exhibition of one or two of the behavioral, verbal, or environmental cues does not necessarily mean that the individual has a mental disorder. For example, someone wearing a bulky winter jacket in warm weather, in some cases, may be more indicative of a potential shoplifter or armed robber than an individual suffering from a mental disorder.
Schizophrenia, hallucinations, delusions, major depression, panic, and bipolar disorder represent some of the conditions that police officers likely will encounter in the field. An effective checklist also should be accompanied by critical information on how further to engage an individual based on the response to checklist items or the individual’s known mental disorder. This may come in the form of a supplemental resource guide provided to officers. A manual for police officers in Ontario, Canada, provides specific guidance on the definition of, recognition of, and appropriate responses to specific mental disorders, as well as more general response options for situations involving persons with mental illnesses. For example, the manual also includes guidance on what to do and not to do when interacting with persons with mental illnesses by offering a general list of appropriate and inappropriate actions as provided in table 2.
It is beneficial to include a mental-health-resource-contact list within the resource guide. For instance, Roanoke County patrol officers have a guide that includes mental health resources, including clinics and 24-hour emergency phone support that could be provided to persons or their families or for an officer to use to seek additional guidance when working with persons in crisis or those with mental illnesses.
Benefits of a Checklist for Law Enforcement
Departments should collaborate with mental health professionals in the preparation of a checklist to ensure that the indicators are valid and that the response guidance is sound.
The development and use of a mental-health checklist for law enforcement offers a number of potential benefits. Such a checklist could increase public and officer safety. The checklist may aid personnel in determining when individuals with a mental disorder pose a danger to themselves or others, including responding officers. In addition, the use of a checklist, especially when combined with CIT training and the availability of a resource guide, may suggest to personnel the most effective tactical approaches for resolving situations and preventing injury.
A mental health checklist also can aid officers in documenting contacts and any concerns raised by an encounter. If part of the record of an encounter, this information can be communicated to other officers to alert them to known issues when responding to subsequent or follow-up calls.
Timely response is critical if a person with a mental disorder needs assistance, psychological care, or medical care. A checklist could help officers identify specific emotional, verbal, and behavioral cues that signal the type of assistance a person might need. Additionally, a checklist could provide officers with guidance about appropriate options for transport and care. Should responding officers transport an individual with mental disorders to a hospital? A jail? A mental health facility? The checklist could serve as a quick classification system for proper transport and immediate care.
The checklist also could aid medical staff and hospital personnel. For example, emergency department personnel, especially in areas where a mental health specialist is not readily available, may find the checklist beneficial for initial screening and referral. It also would allow officers to record why they believed a subject posed potential danger or required assistance, using terms or criteria consistent with medical language.
Discussions following CIT training and in conjunction with a mental-health-screening-checklist may lead police officers to reevaluate certain policies and procedures when dealing with individuals with mental disorders. This could include changes in education and training about how to deal with mental illness, possibly leading to the assessment of current strategies and the development of new ones.
If appropriately validated and regularly updated in consultation with mental health professionals, a mental-health checklist could benefit an agency faced with a claim that it did not adequately train officers on how to respond to individuals exhibiting mental illness. A checklist could be considered in a civil action, criminal proceeding, or internal investigation to demonstrate that the officers considered relevant and appropriate factors when making strategic and tactical decisions related to interactions with persons with mental disorders.
When confronting individuals with mental illness, officers sometimes are viewed as “bullies” by members of the public who may question an officer’s handling of an incident. Questions may include, “Did the officer have to strike the subject?” or “Why was the person arrested?” Because a screening checklist may provide officers with a variety of options for effectively interacting with persons with mental disorders, the effective use of the checklist could address public concerns that officers did everything in their power to appropriately resolve a potentially dangerous situation to a satisfactory end. In addition, the construction of a checklist could include working partnerships between police agencies and local mental health communities, helping to build positive community relationships.
While a mental health screening tool and accompanying resources offer many benefits, agencies must acknowledge the potential limitations. These screening tools do not exist for diagnostic purposes, but, rather, as a guide to help officers best determine how to approach an individual or a situation. To this end, some circumstances may benefit more from their utility, such as when officers have the time (even if brief) to use them and to do so in a manner that does not jeopardize the safety of officers, suspects, bystanders, or others. Its use in a barricade or hostage situation, such as the one presented at the beginning of the article, may have particular value. In other situations, it may not be the deployment of the screening instrument itself so much as the training on resource materials that accompany it that has the greatest benefit. Prior research has found that training beyond academy requirements is essential for helping officers to know how to respond to persons with mental illness. Training guided by a screening tool that emphasizes effective strategies for working with or responding to persons with mental illness further can enhance the effectiveness of CIT programs and raise awareness among first responders, even without full CIT training.
A mental-health checklist can offer much to law enforcement agencies. Departments should collaborate with mental health professionals in the preparation of a checklist to ensure that the indicators are valid and that the response guidance is sound. Once the checklist is written, officers should receive appropriate training. Guidelines for use should be incorporated into agency policy and accompanied by an interpretative supplement for officer training and reference. In addition, several other recommendations could serve to enhance the use of a checklist.
1) Combine the mental health screening checklist with CIT training. CIT training often includes seminars and speakers from a variety of professions, including mental health. The checklist not only would benefit law enforcement but medical professionals, as well. Cotraining can ensure the effective use of the checklist and effective responses to issues involving mental illness; collaborations between law enforcement and mental health agencies also can help ensure the validation of the checklist and recommendations in the accompanying resource guide. The checklist does not replace mental-health training. Rather, it serves as a tool combined with comprehensive mental-health training, such as CIT. For officers who work in a campus environment, the checklist also may prove useful in threat assessment training and practice.
2) Make the checklist and resource guide available as an application for a smartphone, tablet, or similar device to increase practicality. Computer and other electronic applications exist to assist officers in the field, including those who aid in the observation of behaviors related to mental health concerns. The mental-health-screening checklist and resource guide can be programmed into a smartphone or similar device to aid officers in identifying behavioral and other warning cues. This could prove particularly useful when completing police reports.
3) Design the checklist for use by dispatch services and Smart911. Individuals can register and provide information about any medical conditions, including mental disorders, in the Smart911 database (or other resource if appropriate). If an individual calls 911 and is incoherent or inaudible by dispatch, the dispatcher can use the program to reference the individual’s health history and send help immediately. If the caller is distraught but still audible, the dispatcher could use the checklist’s verbal cues to help identify the caller’s problem. The dispatcher then could proceed to use the mental health resource guide to help the caller. The information also could be forwarded to responding officers to assist them in handling the situation.
Police often must address situations involving mentally ill persons who may be suspects, persons in need of protection, or individuals in need of assistance. Accordingly, officers must be well-prepared to recognize and appropriately respond to indicators of mental illness. A brief, valid, and readily available mental health checklist may better serve the community, the law enforcement agency and its personnel, and the person with the mental illness.
Mr. Mason can be contacted at firstname.lastname@example.org; Dr. Burke can be contacted at email@example.com; and Dr. Owen can be contacted at firstname.lastname@example.org.
 Rockwell v. Brown, 664. F.3d 985 (5th Cir. 2011).
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (Washington, DC: American Psychiatric Association, 2013).
 Ibid; and American Psychiatric Association, DSM-5: The Future of Psychiatric Diagnosis, http://www.dsm5.org/Pages/Default.aspx (accessed August 15, 2013).
 National Institute of Mental Health, “The Numbers Count: Mental Disorders in America,” http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml (accessed August 15, 2013).
 Eric Elbogen and Sally Johnson, “The Intricate Link Between Violence and Mental Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions,” Archives of General Psychiatry 66, no. 2 (2009): 152-161.
 Michael Compton and Raymond Kotwicki, Responding to Individuals with Mental Illnesses (Sudbury, MD: Jones and Bartlett Publishers, 2007).
 Ibid; and National Coalition for the Homeless, “Mental Illness and Homelessness,” http://www.nationalhomeless.org/factsheets/Mental_Illness.html (accessed August 15, 2013).
 Richard Lamb and L. Bachrach, “Some Perspectives on Deinstitutionalization,” Psychiatric Services 52, no. 8 (2001): 1039-1045; and National Coalition for the Homeless, “Mental Illnesses and Homelessness.”
 Henry Steadman, “Jail Diversion for the Mentally Ill: Breaking Through the Barriers,” The National Coalition for the Mentally Ill in the Criminal Justice System, http://static.nicic.gov/Library/008754.pdf (accessed August 15, 2013).
 National Institute of Mental Health, “The Numbers Count: Mental Disorders in America”; and Doris James and Lauren Glaze, “Mental Health Problems of Prison and Jail Inmates,” U.S. Department of Justice, Office of Justice Programs, http://bjs.ojp.usdoj.gov/content/pub/pdf/mhppji.pdf (accessed August 15, 2013).
 Ibid; and Doris James and Lauren Glaze, “Mental Health Problems of Prison and Jail Inmates.”
 These screening tools serve as a different type of application than what may be employed by law enforcement.
 Frank Hooper and Mark Welsh, “Mental Health and Law Enforcement Encounters: A Review of Current Problems and Recommendations,” Georgia Association of Chiefs of Police Mental Health Committee, http://www.gachiefs.com/pdfs/NEWS_GACP%20Mental%20Health%20Report.pdf (accessed August 28, 2013).
 Henry Steadman, Pamela Robbins, Tariqul Islam, and Fred Osher, “Revalidating the Brief Jail Mental Health Screen to Increase Accuracy for Women,” Psychiatric Services 58, no. 12 (2012): 1598-1601; and Henry Steadman, Jack Scott, Fred Osher, Tara Agnese, and Pamela Robbins, “Validation of the Brief Jail Mental Health Screen, Psychiatric Services 56, no. 7 (2005): 816-822.
 Henry Steadman, Jack Scott, Fred Osher, Tara Agnese, and Pamela Robbins, “Validation of the Brief Jail Mental Health Screen, Psychiatric Services 56, no. 7: 816-822.
 Steadman et al., “Revalidating the Brief Jail Mental Health Screen.”
 Hooper and Welsh, “Mental Health and Law Enforcement Encounters.”
 Johnny Jines, “Crisis Intervention Teams: Responding to Mental Illness Crisis Calls,” FBI Law Enforcement Bulletin January 2013; and Abigail Tucker, Vincent Van Hasselt, Gregory Vecchi, and Samuel Browning, “Responding to Persons with Mental Illness,” FBI Law Enforcement Bulletin, October 2011, 1-6.
 http://www.calea.org/content/mental-health-training (accessed September 6, 2013)
 Compton and Kotwicki, Responding to Individuals with Mental Illnesses.
 Interview by Christian Mason with Sergeant Mark Jervis, “CIT Training and Dealing with the Mentally Ill,” October 14, 2012; and Mental Health America, http://www.nmha.org/ (accessed August 15, 2013).
 Mental Health America.
 Interview with Sergeant Mark Jervis.
 Code of Virginia, Section 37.2-808, Part G.
 Interview with Sergeant Mark Jervis.
 Ramesh Nyberg, “Damaged: Understanding and Responding to the Problems Involving the Mentally Ill Tend to Be Both Challenging and Difficult to Manage,” Police and Security News 28, no. 5 (2012): 8-11.
 Hooper and Welsh, “Mental Health and Law Enforcement Encounters.”
 Ron Hoffman and Laurel Putnam, “Not Just Another Call: Police Response to People with Mental Illnesses in Ontario,” (Sudbury, Canada: Center for Addiction and Mental Health, 2004).
 Interview with Sergeant Mark Jervis.
 Tucker et al., “Responding to Persons with Mental Illness.”
 Kevin Pieper, “Smart911 Being Adopted by Growing Number of Communities,” USA Today, http://usatoday30.usatoday.com/news/nation/story/2012-07-12/smart911-database/56285514/1 (accessed August 15, 2013).