Course:SOWK551/2021/Mental Health and Policing
Literature review on the role and consequence of police involvement in mental health response.
Date: December 2022
Global social movements have called attention to police brutality and have demanded community based alternatives. Still, police are increasingly involved in the area of mental health resulting in both “acute chronic mental health and health inequities” (Jacobs et al., 2021, p. 51). Police are “gatekeepers” to the mental health system (Lavoie et al., 2022, p. 589). In light of recent movements to defund the police, this paper examines literature on the role and consequences of police involvement in mental health response and ultimately demonstrates that while police claim to protect and serve, they are a source of profound harm on people with mental health challenges. Persons with mental health challenges (PwMHC) will be used to describe individuals with mental illness or those in mental health crises throughout this paper. In conducting research for this paper, literature from North America over the last decade was analyzed. The literature reviewed narrowed in on British Columbia (BC), particularly the Downtown Eastside (DTES) in Vancouver, and the intersections of race and mental health. First, this paper contextualizes police involvement in mental health, providing information about deinstitutionalization. Next, criminalization of mental illness is discussed, as well as police interactions with PwMHC in the community. Additionally, this paper examines formal ways that police are involved with PwMHC, including the Mental Health Act (MHA) and co-responder models. Following this, the effects of policing on PwMHC are analyzed. Next, implications for hospital workers are discussed. In conclusion, social work collaboration with police is reflected on.
Deinstitutionalization and Criminalization of Mental Illness
Boyd and Kerr (2015) explain that the process of “deinstitutionalization” involved the closure of “psychiatric care facilities” and a shift from institutional settings to more “home-like settings”, where mental health services were to be delivered in community (p. 424). Importantly, Boyd and Kerr (2015) point out that housing and community services lacked the appropriate funding to respond to this significant change in mental health services. Koziarski et al. (2021) assert that deinstitutionalization and a lack of adequate mental health and housing supports are all factors in the over-policing of PwMHC.
Combined with a lack of services in the community, mental health can overlap with many other aspects of identity, causing complex and compounding forms of marginalization and oppression. Kolar et al. (2022) note that intersecting social factors such as “poverty, homelessness, ableism, colonialism, racism, transphobia and homophobia” all influence mental health outcomes (p. 9). Roa (2021) adds that the “legacy of colonialism, slavery and ongoing structural racism” create conditions where Black, Indigenous, and people of colour (BIPOC) populations are particularly vulnerable to violent forms of policing (p. 2). Koziarski et al. (2021) cite that in Canada, “persons with perceived mental illness are four times more likely to be arrested” than the general population (p. 979). Taken all together, mental health issues combined with compounding forms of oppression make those at the intersections of marginalizations acutely vulnerable to be targeted by police.
Criminalization of mental illness is “causally linked deinstitutionalization” with an increase of MwMHC having criminal justice system involvement (p. Parpouchi et al., 2021, p. 2). PwMHC also contend with social stigma and stereotypes which depict mental illness as inherently dangerous and criminal (Boyd & Kerr, 2016). Criminalization combined with stigma contributes to over policing of populations with mental health issues. (Parpouchi et al. 2021). Parpouchi et al. (2021) explain that when PwMHC are involved in crime, it is generally an “adaptive survival strategy” resulting from impoverished conditions (para 25). Still, in contrast to public perception of mental illness, those PwMCH are more likely to be the victims of crime rather than perpetrators (Dempsey, 2020).
PwMCH come into contact with police through a variety of interactions (Boyd & Kerr, 2016). Gur (2013) explains that in Canada, PwMCH interacts with police for “general occurrences” such as “traffic violations, trespassing, public disturbance, street checks, or complaints” (p. 227). Research by Parpouchi et al. (2021) show that in the DTES, criminalization, combined with a lack of protection and reliance on public space makes PwMHC vulnerable to disproportionate levels of policing. Finally, Pearce and Simpson (2022) add that a common way in which people with mental illness come into contact with police is through “wellness checks” where the “police are tasked with checking on the wellbeing of an individual'' (p. 401). Further, research shows that once an individual is known to police, they are more likely to be targeted through future police interaction (Parpouchi et al., 2021).
Involvement of Police in Mental Health Services
As discussed, the BC MHA came into effect following deinstitutionalization (Kolar et al., 2022). The MHA in BC “describes the process whereby ‘a person with a mental disorder or a person with an apparent mental disorder’ is ‘detained or taken charge of’ for purposes of ‘receiving care, supervision, treatment, maintenance or rehabilitation’ (Kolar et al., 2022, p. 8). Importantly, section 21(1) allows for the police to apprehend citizens, who by their own assessment are “acting in a manner likely to endanger their own safety or that of others” (Kolar et al., 2022, p. 8). Once apprehended, a PwMHC is brought to the hospital for psychiatric assessment to determine eligibility for certification. While Section 28(1) of the MHA provides the police with far reaching authority to intervene in mental health crises, research shows that police do not possess the knowledge or skills to be able to properly assess or offer appropriate interventions (Huey, et al., 2022).
Despite their apparent lack of ability to deal with mental health issues, police still position themselves as the “de-facto 24 hour mental health emergency response” (Boyd & Kerr, 2016). The Vancouver Police Department have authored numerous reports including Project Lockstep, Policing Vancouver’s Mentally Ill: The Disturbing Truth, and most recently Vancouver’s Social Safety Net: Rebuilding the Broken, which all highlight the role of police in responding to PwMHC and the inadequate resources the department has in terms of addressing the challenges, particularly mental health, in the DTES. These reports emphasize the collaboration between health and social services and the police department necessary to address the complex intersecting issues, including mental health issues that disproportionately affect the DTES population.
The Vancouver Police Department have made efforts to respond to the mental health needs through increased training and education. Michalski (2016) notes that the Vancouver Police Department has implemented training programs such as “Crisis intervention and De-escalation” training which every police officer must complete (p. 8). Michalski (2016) explains that these programs are intended to expand awareness of mental health and aid police officers in responding appropriately to mental health crises, and “reduce risks of lethal force” (p. 8). Additionally, the Vancouver Police Department has created education for officers on stigma around mental health, informed by those with lived experience of mental illness (Vancouver Police Department, 2022). Costigan (2022) explains that such efforts can reduce risk of traumatic experiences that PwMHC may experience with police.
In addition to police being involved in processes related to the MHA, and increased training and education, police have also been integrated into community mental health responses such as Car 87, Assertive Community Treatment Teams (ACT), and Assertive Outreach Teams (Vancouver Police Department, 2022). Police collaboration with mental health professionals is referred to as the “co-responder model” and is used across many Canadian cities (Marcus & Stergiopoulos, 2021, p. 1). Service recipients of ACT Teams report that officers were more invested in the health and wellbeing of service recipients than with police officers with whom they had “no relationship” (Costigan et al., 2022, p. 450). Lavoie et al. (2022) write that police responding to mental health calls with little context or information about the individual can increase risk associated with the call. In this way, police relationships with PwMHC can allow for more informed assessment of risk and more proportionate responses. While these models may reduce harm, Marcus and Stergiopoulus (2021) underscore that BIPOC populations and other communities historically impacted by police violence may have dissenting views on co-responder models.
Effects of Policing on Health
While police are called on to prevent harm, paradoxically, interactions with police have been shown to be violent and can profoundly endanger the health and wellbeing of PwMHC. Lavoie et al. (2022) explains that police presence on its own is enough to “escalate” a person in a mental health crisis and that police already assess PwMHC as being inherently dangerous (p. 589). This can result in a dynamic where PwMHC are less likely to comply out of fear, and police are even more likely to respond with excessive force (Lavoie et al., 2022). Research by Koziarski et al. (2021) shows that PwMHC are subject to police violence including being “pushed, punched, kicked, or having a weapon used on them (e.g., baton, taser, firearm) (p. 979). Importantly, Koziarski et al. (2021) describe that women with mental health challenges also experience sexual violence at the hands of police officers. Kolar et al. (2022) explains that the drug toxicity crisis and the COVID-19 pandemic have worsened mental health, resulting in increased rates of “police interventions using excessive force” (p. 2).
In addition to sustaining physical injury, PwMHC may experience psychological injury from involvement with the police. Simckes et al. (2021) state that involuntary contact with police impacts overall “health and wellbeing” of people with mental illness, adding that “trauma” and “post-traumatic stress disorder” are among the psychological effects (p. 4). Police interactions cause a host of negative psychological outcomes, deepening the already suffering mental health of PwMHC. Simckes et al. (2021) note that involuntary interactions with police have adverse impacts not only on the individual level but on “the social fabric and health of communities” (p. 112). This is especially important in relation to communities who already experience structural oppression and a lack of access to social determinants of health (Alang et al., 2021). Baker and Pillinger (2019) cite that in Canada, research shows that people who live with mental illness are “disproportionately more likely to die after police contact,” (p. 110). The BC Government report “Opportunities for Different Outcomes” reviewed 127 police-related deaths in BC in a 5 year period and revealed that mental health symptoms were a primary reason that police were called in these cases (Public Safety and Solicitor General, 2019).
Examining the intersections of race and mental health in the Canadian context, Rao (2021) articulates the danger of police in responding to the mental health of BIPOC communities. Roa (2021) writes that “structural racism” and mental health challenges results in BIPOC communities being targets of police violence (p. 2). Illustrating this, Roa (2021) names 6 BIPOC individuals experiencing mental health distress that were killed by police over a 3 month period in 2020. BC Government’s Public Safety and Solicitor General (2019) highlights that although Indigenous populations only make up “6% of the population” they account for “20%” of police related deaths (para. 3). Further research affirms that Black populations who live with mental illness are disproportionately killed by police, as were people of colour (Huey et al., 2021). On police killings, Baker and Pillinger (2019) state “Obviously, to reduce the number of deaths after police contact is to reduce the number of contacts vulnerable individuals have with police” (p. 19).
Implications for Hospital Social Workers
While police respond come into contact with PwMHC in the community, police routinely receive calls from healthcare services. Vancouver Police Department data shows that in 2020, “26% of mental health related calls for service were from healthcare or social work staff requesting police assistance” (Huey et al., 2021). Huey et al. (2021) assert that in many of these mental health related calls, police are called to respond to threats of or actual violence against healthcare workers. Pepler et al. (2021) explain that “substantial research” indicates that the healthcare system must move from a reactive approach to “crime events” towards a “holistic approach that results in better individual outcomes, increased public safety, and reduced police involvement” (p. 95).
While being mindful not to place responsibility on healthcare workers who endure violence in their work, it is important to critically examine the ways in which healthcare responses can be more holistic. On working with PwMHC at the micro level in healthcare settings, Kolar et al. (2021) recommend adopting an “equity orientation” (p. 14). Kolar et al. (2021) define an equity orientation as incorporating “trauma-and violence informed care, harm reduction, anti-racism, and culturally safe care, and gender-affirming care” and treatment approaches that are “non-coercive and anti-oppressive” (p. 14). Approaching PwMHC in healthcare settings from an “equity orientation” can support foundations of trust and respect, which Alang et al. (2021) assert are critical in supporting patients with mental health challenges. Supporting PwMHC from an equity orientation can decrease the likelihood of patients becoming escalated, thereby reducing the need for police involvement (Lavoie et al., 2022). Jacobs et al. (2021) assert that calling police to respond to crisis situations in hospitals can result in a rupture in trust between patients seeking care and healthcare providers, as well as the healthcare system as a whole. While police may be “deployed” to healthcare settings in an attempt to protect patients and staff, Jacobs et al. (2021) argue that a “growing body of evidence” demonstrates that police increase the risk of “harm and death” to patients (p. 51). For these reasons, it is vital that social workers weigh the risks of calling police in situations involving PwMHC, and to look towards less reactive approaches (Pepler et al., 2021).
Kolar et al. (2021) stress that systems advocacy is necessary in working with PwMHC. Returning to de-institutionalization, this could include advocating for more funding for mental health services. Affirming this, Marcus and Stergiopoulos (2021) assert that funding should be “redirected” from police budgets towards health care services to “support and sustain” more holistic and community-based forms of care which do not rely on law enforcement (p. 1675). This re-allocation of funding also aligns with demands from BIPOC communities to defund the police.
The literature examined throughout this paper have revealed tensions in how involved police should be in responding to PwMHC. While integration of police into co-responder models have shown promise in reducing the harm that police may cause, critics have argued that police integration into mental health response teams “blurs the distinction between health care and criminal justice activity” (Costigan et al., 2022, p. 448). Moreover, the literature reviewed here overwhelmingly demonstrates the adverse impacts of policing on PwMHC, including harm at the micro and macro level (Alang et al., 2021). For social workers in particular, Jacobs et al. (2021) express that the profession must grapple with its own “oppressive history” and align with shifts from policing to less harmful “interventions” (p. 55). Police do not protect those with PwMHC, and it is critical that social workers who are committed to social justice continue to seek out alternatives to police involvement that support the health, wellbeing and self-determination of PwMHC.
Alang, S., Rogers, T., Williamson, D., Green, C., & Bell, J. (2021). Police brutality and unmet need for mental health care. Health Serv Res, 56(6), 1104-1113. https://doi.org/10.1111/1475-6773.13736
Boyd, J., & Kerr, T. (2015). Vancouver’s mental health crisis’: A critical discourse analysis. Critical Public Health, 26(4), 419-433. https://doi.org/10.1080/09581596.2015.1007923
Costigan, C., Woodin, E., M., Duerksen, M., Ferguson, R. (2022). Benefits and drawbacks of police integration into Assertive Community Treatment teams. Psychiatric Services, 73(4), 447-455. https://doi.org/10.1176/appi.ps.201900549
Dempsey, C., Quanbeck, C., Bush, C., & Kruger, K. (2020). Decriminalizing mental illness: Specialized policing responses. CNS Spectrums, 25(2), 181-195. https://doi.org/10.1017/s1092852919001640
Gur, O. (2013). Persons with mental illness in the criminal justice system: Police interventions to prevent violence and criminalization. Journal of Police Crisis Negotiations, 10(1-2), 220-240. https://doi.org/10.1080/15332581003799752
Huey, L., Ferguson, L., & Schulenberg, J. L. (2022). The wicked problems of police reform in Canada (1st ed.). Routledge. https://doi.org/10.4324/9781003296447
Huey, L., Ferguson, L., & Vaughan, A. D. (2021). The limits of our knowledge: Tracking the size and scope of police involvement with persons with mental illness. Royal Society of Canada. https://rsc-src.ca/sites/default/files/MH%26P%20PB_EN.pdf
Jacobs, A., Kim, M., Whitfield, A., Gartner, R., Panichelli, S., Kattari, S., Downey, M., McQueen, S., & Mountz, S. (2021). Defund the police: Moving towards anti-carceral social work. Journal of Progressive Human Services, 32(1), 37-62. https://doi.org/10.1080/10428232.2020.1852865
Kolar, M., Varcoe, C., & Brown, H. (2022). Involuntary psychiatric treatment and the erosion of consent: A critical discourse analysis of mental health legislation in British Columbia, Canada. Health, 00(0), 1-20. https://doi.org/10.1177/13634593221096241
Koziarski, J., O’Connor, C., & Frederick, T. (2021). Policing mental health: The composition and perceived challenges of co-response teams and the crisis intervention teams in the Canadian context. Police Practice and Research, 22(1), 977-995. https://doi.org/10.1080/15614263.2020.1786689
Lavoie, A., J., Alvarez, N., & Kandil, Y. (2022). Developing community co-designed scenario-based training for police mental health crisis response: A relational approach to de-escalation. Journal of Police and Criminal Psychology, 37(1), 587-601. https://doi.org/10.1007/s11896-022-09500-2
Michalski, J. (2016). Mental health issues and the Canadian criminal justice system. Contemporary Justice Review, 20(1), 2-25. https://doi.org/10.1080/10282580.2016.1226817
Peace & Simpson (2022). The role of police in conducting wellness checks: Insight from a study of police data. Police Practice & Research, 23(4), 400-413. https://doi.org/10.1080/15614263.2022.2042292
Pepler, E. F., & Barber, C., G. (2021). Mental health and policing: Picking up the pieces in a broken system. Healthcare Management Forum, 34(2), 93-99. https://doi.org/10.1177/0840470420979635
Public Safety and Solicitor General. (2019, June). Police de facto part of mental health system: Death review panel. BC Government. https://news.gov.bc.ca/releases/2019PSSG0058-001150
Roa, S. (2022). Black lives, blue shirts and ‘colourblindness’: Application of critical race theory in police response models for persons with mental illness. Community Mental Health Journal, 58(1), 1-10. https://doi.org/10.1007/s10597-021-00888-5
Simckes, M., McFarland, M., McFardland, C., Rowhani-Rahbar, A., & Hajat, A. (2021). The adverse effect of policing on population health: A conceptual model. Social Science & Medicine, 281(1), 103-114. https://doi.org/10.1016/j.socscimed.2021.114103
Vancouver Police Department. (2022). Mental health initiatives. https://vpd.ca/policies-strategies/mental-health-initiatives/
Vancouver Police Department. (2010, September). Policing Vancouver’s mentally ill: The disturbing truth. https://vpd.ca/wp-content/uploads/2021/06/vpd-lost-in-transition-part-2.pdf
Vancouver Police Department. (2009, February). Project lockstep: A united front to save lives in the Downtown Eastside. https://vpd.ca/wp-content/uploads/2021/06/vpd-project-lockstep.pdf
Vancouver Police Department. (2022, November). Vancouver’s social safety net: Rebuilding the broken. https://vpd.ca/wp-content/uploads/2022/11/vancouvers-social-safety-net-rebuilding-the-broken.pdf