IJLP-01013; No of Pages 7 International Journal of Law and Psychiatry xxx (2014) xxx–xxx
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International Journal of Law and Psychiatry
Perceptions and experiences of people with mental illness regarding their interactions with police James D. Livingston a,⁎, Sarah L. Desmarais b, Simon Verdun-Jones c, Richard Parent c, Erin Michalak d, Johann Brink d,e a
Department of Sociology & Criminology, Saint Mary's University, Nova Scotia, Canada Department of Psychology, North Carolina State University, North Carolina, USA School of Criminology, Simon Fraser University, British Columbia, Canada d Department of Psychiatry, University of British Columbia, British Columbia, Canada e Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, British Columbia, Canada b c
a r t i c l e
i n f o
Available online xxxx Keywords: Police Mental Illness Perceived Procedural Justice Mixed method
a b s t r a c t This study examined the perceptions and lived experiences of people with mental illness in relation to their interactions with the police. A community-based participatory research approach was used and a procedural justice theoretical perspective guided the study. In-depth, semi-structured interviews were conducted by peer researchers with 60 people with mental illness who had interacted with the police and were living in Metro Vancouver, Canada. Among the study participants, contact with the police was frequent and occurred under a diverse range of circumstances. The majority of participants perceived being treated in a procedurally just manner by the police officer(s) who were involved in their most recent interaction. Almost three-quarters (n = 43, 72%) of participants were generally satisfied with how the police officer(s) had handled their most recent interaction. The slight majority of participants (n = 30, 51%) rated their previous contacts with the police as a positive experience overall, with 32% (n = 19) indicating that their previous interactions with the police were negative life experiences. The findings paint a more balanced picture than that which is often portrayed by the media. Emphasizing a procedural justice framework for police handling of situations involving people with mental illness is a vital step toward improving how these interactions are experienced and perceived. © 2014 Published by Elsevier Ltd.
1. Introduction In contrast with popular media depictions (Sieff, 2003; Stout, Villegas, & Jennings, 2004), most people with mental illness do not commit criminal or violent acts; however, research suggests that contact with the police is common among this population (Bloom, Rogers, Manson, & Williams, 1986; Gelberg, Linn, & Leake, 1988; Holcomb & Ahr, 1988; Theriot & Segal, 2005). Explanations for the occurrence of these interactions are complex, but generally focus on clinical risk factors, such as co-occurring substance use problems and treatment non-adherence, as well as social and systemic factors, including deinstitutionalization policies, homelessness, poverty, community disorganization, poorly funded and fragmented community-based services, hospital emergency room bed pressures, overly restrictive civil commitment criteria, intolerance of social disorder, and criminal law reforms (Borum, Swanson, Swartz, & Hiday, 1997; Cotton & Coleman, 2010;
⁎ Corresponding author at: 923 Robie Street, Halifax, Nova Scotia, B3H3C3, Canada. Tel.: +1 902 491 6258; fax: +1 902 520 5121. E-mail address: [email protected] (J.D. Livingston).
Lamb, Weinberger, & Gross, 2004; Silver, 2006; Van Dorn, Volavka, & Johnson, in press). Furthermore, the police play a pivotal role in the application of both civil commitment legislation and criminal procedure on account of their mandated role in society, contributing to the frequency of encounters with people who have mental illness (Cotton & Coleman, 2010). Increasingly, police officers have assumed expanded functions of maintaining social order, which include responding to mental health crises (Lamb et al., 2004; Patch & Arrigo, 1999). As a result, they can significantly influence the lives of people with mental illness. Police are often the principal first responders to situations involving people with mental illness, which has earned them the monikers “de facto mental health service providers” (Patch & Arrigo, 1999) and “psychiatrists in blue” (Menzies, 1987). In many situations, police officers have considerable discretion to use a range of informal or formal interventions, thereby assuming a gatekeeper function to the mental health and criminal justice systems (Lamb, Weinberger, & DeCuir, 2002; Patch & Arrigo, 1999; Watson, Corrigan, & Ottati, 2004). Many factors affect the subjective experience of interacting with the police. In addition to the purpose or outcome of the interaction, procedural justice theory suggests that the perceived fairness with which
http://dx.doi.org/10.1016/j.ijlp.2014.02.003 0160-2527/© 2014 Published by Elsevier Ltd.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
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people are treated during police interactions influences their subjective experience of the encounter (Cascardi, Poythress, & Hall, 2000; Wales, Hiday, & Ray, 2010; Watson & Angell, 2007). Accordingly, the degree to which police officers treat people with dignity and respect, provide them with opportunities to present their own side of the story, and appear concerned for their welfare is likely to affect the nature and perception of these encounters (Watson & Angell, 2007). This is consistent with research showing that people with mental illness who feel powerless and coerced tend to experience higher levels of internalized stigma (Link, Castille, & Stuber, 2008). Internationally, police services are investing considerable resources in initiatives, such as specialized police response programs and training, designed to improve the manner in which officers respond to and interact with people who have mental illness (Cotton & Coleman, 2010; Parent, 2007; Price, 2005; Steadman, Deane, Borum, & Morrissey, 2000; Tucker, Van Hasselt, & Russell, 2008). Many of these efforts have been triggered by inquiries into fatal encounters involving the police and people with mental illness. A significant limitation of these important initiatives is that they have not been systematically informed by the perspectives and experiences of people who live with mental illness, likely due in part to the dearth of research in this area. We are aware of only two systematic studies that have examined in-depth the perceptions and experiences of people with mental illness regarding their encounters with the police: the first involved interviews with 26 community mental health service users (Watson, Angell, Morabito, & Robinson, 2008) and the second was comprised of interviews with 16 individuals with psychotic illnesses who had been detained by the police (Jones & Mason, 2002). Together, findings of these studies indicate that perceptions vary and are heavily influenced by the attitudes and behaviors of police officers; however, the generalizability of results derived from such small samples is questionable and further research is required. Using a community-based research approach and guided by procedural justice theory, the present study contributes to this body of knowledge by examining the perceptions and experiences of people with mental illness in relation to their interactions with the police. 2. Method The study protocols were approved by the research ethics committees of the University of British Columbia, Simon Fraser University, and relevant health agencies. 2.1. Community-based participatory research (CBPR) approach The present study focused on sensitive issues involving power differentials among a marginalized population. As such, we employed an inclusive and collaborative research strategy. CBPR describes a way of engaging community members in research; their involvement is not limited to the role of research subject, but rather they are actively engaged in all stages of the research process and are involved in cocreating the findings (Minkler & Wallerstein, 2008). Accordingly, people with mental illness were involved in multiple levels of this project: the research team included people who have lived experience with mental illness, the research materials were developed in consultation with people who have mental illness, and the data collection process was led and performed by peer researchers. 2.2. Participants From April to December 2010, 60 participants were recruited from mental health centers and agencies in Metro Vancouver, Canada. Study inclusion criteria were: (a) current diagnosis of schizophrenia, schizoaffective disorder, other psychosis, or bipolar disorder (selfreported); (b) previous contact with police (self-reported); (c) age
19 years or older; (d) able to speak and understand English; and (e) cognitively capable of providing research consent. 2.3. Materials A semi-structured interview guide was developed in consultation with content experts, including people with mental illness who had previous contact with the police. The guide contained detailed questions regarding participants' most recent police encounter, with several items drawn from the Police Contact Experience Scale (PCES) (Watson, Angell, Vidalon, & Davis, 2010). The PCES is a standardized measure for assessing situational, procedural, and interpersonal aspects of interactions between people with mental illness and the police. The PCES includes a ten item perceived procedural justice (PPJ) subscale that assesses the extent to which someone believes they have been treated in a procedurally just manner by the police. The PCES also contains a five item perceived coercion (PC) subscale that measures subjective experiences of coercion and a four item satisfaction subscale that assesses the degree to which participants felt that their situation was handled appropriately by police. Additionally, a three item outcome favorability subscale evaluates participants' perspectives regarding the disposition of a police interaction. All items are rated on a 4-point scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (4). Higher scores on the subscales indicate higher levels of the corresponding construct (e.g., procedural justice, coercion). Participants' lifetime police interactions were also queried, including frequency and types of contact. In addition, participants were asked to indicate whether their previous interactions were perceived as positive or negative experiences overall, on a 5-point scale ranging from ‘very negative’ (1) to ‘very positive’ (5). Finally, participants were asked to identify ways to improve how the police handle situations involving people with mental illness. 2.4. Procedures A range of recruitment strategies was used, including distributing advertisements via email, posters, websites, e-newsletters, and at consumer events. The advertisements provided a brief study description and instructions for contacting the research team. Potential participants were screened for inclusion by a graduate-level research assistant either in person or by telephone. The consent form was reviewed with the potential participant and questions answered. Eligible individuals were booked for an appointment during which a peer researcher obtained written informed consent and proceeded with the interview. Interviews were conducted in private, lasting approximately 60 min. Digital recordings of the interviews were transcribed verbatim. Participants were paid $10 for their contributions. 3. Results 3.1. Participants Participant characteristics are summarized in Table 1. Women represented approximately one-third (n = 19, 32%) of the sample. Over three-quarters (n = 47, 78%) self-identified as White/Caucasian. The average age was 45.2 years (SD = 10.7); however, the youngest age group (19 to 29 years) was only comprised of four participants. Most (n = 54, 90%) had a household income of less than $25,000 CDN and most (n = 38, 63%) had experienced homelessness. More than half (n = 33, 55%) had a history of problematic substance use. Past year victimization was reported by 37% (n = 22) of participants. Almost all participants (n = 56, 93%) had been the victim of a crime during their lifetime, including 72% (n = 49) who had been violently victimized. Thirteen percent (n = 8) perpetrated a criminal act within the past year. The majority (n = 44, 73%) reported perpetrating a crime during their lifetime, with 53% (n = 32) of participants
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx Table 1 Participant characteristics. Characteristics Gender Male Female Age, in years Mean ± SD Ethnicity White/Caucasian Aboriginal Asian Other/multiple Country of birth Canada Other Primary language English Other Employment status Paid employment Not employed Household income b$25,000 CDN N$25,000 CDN Education level Did not complete high school/GED Completed high school/GED History of homelessness Lifetime, yes Past year, yes Primary psychiatric diagnosis Schizophrenia Schizoaffective disorder Bipolar disorder Other psychotic disorder History of problematic substance use Yes No History of involuntary psychiatric hospitalization Yes No
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Table 2 Nature of interactions with the police. n
%
41 19
68 32
57
45.2 ± 10.7
47 5 3 5
78 8 5 8
49 11
82 18
53 7
88 12
29 31
48 52
one-third of participants (n = 21, 35%) interacted with the police in the context of mental health crises during their lifetime.
54 6
90 10
3.4. Use of force by police officers
16 44
27 73
38 9
63 15
20 15 20 5
33 25 33 8
33 27
55 45
46 11
81 19
committing violent crimes. Over their lifetime, just fewer than half (47%, n = 28) had been convicted of criminal offenses and 35% (n = 21) had been adjudicated ‘Not Criminally Responsible on account of a Mental Disorder’. 3.2. Number of interactions Numerous and recent contacts with the police were common. Onethird (n = 20, 33%) of participants had at least one police contact during the month prior to the interview. Two-thirds (n = 40, 67%) of participants interacted with the police in the past year, including 13% (n = 8) who had six or more encounters. The sample reported the following number of lifetime interactions with police: 1 contact (n = 1, 2%), 2 to 5 contacts (n = 10, 17%), 6 to 10 contacts (n = 17, 28%), 11 to 25 contacts (n = 10, 17%), and 26 or more contacts (n = 22, 37%).
Reasons
Casual or informal Street stop/check Committed a criminal offense Requested assistance as a victim of a crime Domestic dispute Requested assistance to report a crime Public disturbance Committed a violent criminal offense Requested assistance as a witness to a crime Mental health crisis Served with a warrant DUI or traffic violation
Lifetime contacts
Most recent contacts
n
Valid %
n
Valid %
45 41 38 33 32 25 24 22 21 21 20 17
75 68 64 55 53 42 40 37 35 35 33 28
5 11 11 11 6 7 7 4 3 17 4 3
8 18 18 18 10 12 12 7 5 28 7 5
During their lifetime, almost three-quarters (n = 43, 72%) of participants reported being handcuffed and 57% (n = 34) had been physically restrained by a police officer — often in the context of a mental health apprehension. More than a quarter (n = 17, 28%) of participants reported having ever been pushed or shoved by a police officer, while 17% (n = 10) had been punched or kicked by a police officer. Almost twothirds (n = 19, 32%) reported having had a weapon (e.g., baton, conductive energy device, firearm) pointed at them by a police officer and 8% (n = 15) had a police issued weapon used against them in their lifetime. A quarter (n = 15, 25%) had previously been involved in police interactions resulting in minor injury to the participant (not requiring medical attention), whereas 12% (n = 7) suffered serious injury (requiring medical attention). Thirty-seven percent (n = 22) of participants felt that the degree of force used by police during previous interactions had been excessive. 3.5. Outcomes of interactions Participants' most recent interactions with the police were primarily resolved through informal means, including the officer taking no action (n = 19, 32%), writing a report (n = 12, 20%), or giving a warning (n = 5, 8%). Police officers also provided assistance during many of the interactions, including taking the participant to hospital for medical (n = 7, 12%) or psychiatric (n = 9, 15%) treatment, referring them to a mental health agency (n = 4, 7%), or providing other forms of assistance (e.g., providing a ride home) (n = 6, 10%). Fifteen percent (n = 9) of participants' most recent interactions resulted in apprehension or arrest (but not taken to hospital). During their lifetime, the vast majority of participants (n = 54, 90%) had been transported (e.g., to hospital or jail) by the police and 77% (n = 46) had been apprehended/arrested.
3.3. Nature of interactions 3.6. Perceptions of most recent interaction As summarized in Table 2, a diverse range of circumstances brought participants into contact with the police. Participants' most recent interaction with the police was most likely to involve a mental health crisis (n = 17, 28%) and least likely to involve a casual or informal encounter (n = 5, 8%). During their lifetime, most participants interacted with the police for reasons that included casual or informal encounters (n = 45, 75%), street stops and checks (n = 41, 68%), being suspected of committing a criminal offense (n = 38, 64%), requesting assistance as a victim of crime (n = 33, 55%), and domestic disputes (n = 32, 53%). Approximately
Ratings on PCES items pertaining to perceived procedural justice, perceived coercion, satisfaction, and outcome favorability are summarized in Table 3. The majority of participants perceived that they had been treated in a procedurally just and fair manner by the police officer(s) who were involved in their most recent interaction. For example, 88% (n = 52) indicated that they were treated humanely and 85% (n = 51) felt treated with respect. Fewer participants (n = 29, 52%) provided favorable ratings regarding the officers' level of concern toward understanding their needs.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
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J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx
Table 3 Perceptions about most recent interaction with the police. Police Contact Experience Scale
Mean ± SD
Perceived procedural justice (α = 0.94) The officer(s) treated me like a human being. The officer(s) were just doing their job. The officer(s) gave me enough time to do what they asked. The officer(s) treated me respectfully. The officer(s) tried to do what they thought was the best for me. I am satisfied with the way the officer(s) dealt with the situation. The officer(s) seemed genuinely concerned about me as a person. The officer(s) took the time to listen and understand my situation. The officer(s) went out of his/her way to be helpful. The officer(s) was concerned about understanding what I needed. Perceived coercion (α = 0.89) I had a lot of control over how the situation was resolved.c I had more influence than anyone else.c I felt free to do what I wanted.c I had a say in how the situation was resolved.c I felt free to say what I wanted.c Satisfaction (α = 0.91) The officer(s) generally did a good job dealing with my situation. I was generally satisfied with the way the officer(s) handled my situation. I was helped by what the officer(s) did. I was helped by what the officer(s) said. Outcome favorability (α = 0.87) The interaction with the officer was resolved the way I wanted it to be. The outcome of the situation with the police was better than I expected. The outcome I received was favorable. a b c
2.93 3.15 3.07 3.07 3.03 2.94 2.93 2.78 2.85 2.81 2.57 2.56 2.78 2.76 2.64 2.58 2.12 2.83 2.97 2.83 2.80 2.71 2.79 2.85 2.75 2.78
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.59 0.67 0.67 0.68 0.74 0.74 0.86 0.77 0.83 0.85 0.76 0.71 0.83 0.80 0.90 0.87 0.85 0.70 0.72 0.85 0.81 0.80 0.71 0.78 0.83 0.82
Disagreea
Agreeb
n
Valid %
n
Valid %
7 9 9 9 14 14 17 17 21 27
13 15 16 15 26 24 29 29 36 48
52 50 48 51 40 44 42 42 37 29
88 85 84 85 74 76 71 71 64 52
39 40 36 31 16
66 68 61 54 27
20 19 23 26 44
34 32 39 46 73
12 17 16 23
20 28 27 40
47 43 43 35
80 72 73 60
15 20 19
25 35 33
44 37 39
76 68 67
Includes ‘strongly disagree’ (1) and ‘disagree’ (2) response options. Includes ‘agree’ (3) and ‘strongly agree’ (4) response options. Reverse coded items.
Perceived coercion was prevalent among participants' most recent police interaction. For instance, 66% (n = 39) did not feel that they had ‘a lot of control’ over the resolution of the situation. In contrast, almost three-quarters (n = 44, 73%) of participants felt free to verbally express themselves during their most recent police interaction. Eighty percent (n = 47) of participants indicated that the police officer(s) did a good job and 72% (n = 43) were generally satisfied with how their most recent situation was handled. Noteworthy is that the majority of participants (n = 44, 76%) also indicated that the police interaction was resolved the way they wanted it to be, with 68% (n = 37) reporting that the outcome was better than expected. Since many police response programs and training have focused on mental health crises, analyses were performed to compare the perceptions of participants whose most recent police interactions were (n = 17) and were not (n = 43) in the context of a mental health crisis. Ratings revealed no significant differences perceived procedural justice, t(58) = 0.73, P N .05, perceived coercion, t(58) = 0.41, P N .05, satisfaction, t(58) = 1.15, P N .05, and outcome favorability, t(58) = 1.09, P N .05. As summarized in Table 4, the four PCES subscales were significantly correlated. Participants' level of satisfaction was strongly correlated with perceptions of procedural justice (r = 0.88, P b 0.001), outcome favorability (r = 0.75, P b 0.001), and perceived coercion (r = −0.67,
P b 0.001). Perceived procedural justice was strongly associated with perceived coercion (r = − 0.77, P b 0.001) and outcome favorability (r = 0.78, P b 0.001). This demonstrates the interrelatedness of processes (i.e., procedural justice, coercion) and outcomes (i.e., favorability, satisfaction) in shaping participants' perceptions of their most recent police interactions.
3.7. Perceptions of lifetime interactions Half of participants (n = 30, 51%) rated their previous contacts with the police as an overall positive experience, with 32% (n = 19) indicating that these lifetime experiences were ‘very positive’. One-third (n = 19, 32%) of participants perceived their interactions with the police as a negative life experience, with 19% (n = 11) rating the experiences as ‘very negative’. Seventeen percent (n = 10) felt that their previous interactions were neither positive nor negative life experiences. Participants' overall ratings of police interactions during their lifetime were moderately correlated with PCES subscale ratings regarding their most recent interaction: perceived procedural justice (r = 0.56, P b 0.001), perceived coercion (r = − 0.55, P b 0.001), satisfaction (r = 0.57, P b 0.001) and outcome favorability (r = 0.53, P b 0.001). This suggests that participants' impressions of previous interactions with the police were linked with perceptions of recent encounters.
3.8. Improving interactions with the police Table 4 Perceptions about most recent interaction with the police. Police Contact Experience Scale
PPJ
PC
S
OF
Perceived procedural justice (PPJ) Perceived coercion (PC) Satisfaction (S) Outcome favorability (OF)
–⁎ −0.77⁎⁎⁎ 0.88⁎⁎⁎ 0.78⁎⁎⁎
−0.77⁎⁎⁎ –⁎⁎ −0.67⁎⁎⁎ −0.61⁎⁎⁎
0.88⁎⁎⁎ −0.67⁎⁎⁎ – 0.75⁎⁎⁎
0.67⁎⁎⁎ −0.54⁎⁎⁎ 0.71⁎⁎⁎ –
⁎⁎⁎ p b 0.001 (2 tailed).
Qualitative data pertaining to participants' recommendations for improving interactions with the police were analyzed by the principal author using a qualitative description approach (Neergaard, Olesen, Andersen, & Sondergaard, 2009). The data was coded, and then sorted and combined based on similar patterns and themes. This section describes the eight major themes, with selected quotes, that emerged from the data.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx
3.8.1. Police access to information Almost all participants indicated that it would be helpful for police officers to have access to personal information about a person with mental illness prior to arriving on scene, such as whether they have a history of suicide or the nature of the mental health problem. One participant indicated the following reason why such information would be helpful to the police: “So they [the police] go into a situation and know how to handle the person, how to speak to the person, know a bit about his background, so they don't offend them or set them off, or how to get the situation under control.” Although participants were generally supportive of the police having access to mental health-related information, they also expressed the need for proper training for police to handle such information in an appropriate manner: “If the system is gonna make the effort to properly train and support people with mental illness living in the community, then I'm all for them [the police] having access to that information. But if they're just gonna continue the … hit first and talk later … I'm not so into giving out that information.” 3.8.2. Police education and training The majority of participants indicated that police training and education were important ways to improve interactions between the police and people with mental illness. They identified the following four critical elements for police training programs. 3.8.2.1. Understanding mental illness and its effects. Many participants spoke about previous police interactions in which the officer(s) did not appear to understand the basics of mental illness, including how it might affect a person's cognition and behavior. The participants felt that increasing knowledge about mental illness, including how it is experienced and how it affects an individual, would improve the attitudes and behaviors of police officers: “I really think there should be some effort made in teaching them [the police] at least the basics of the types of mental illness and what can be expected from somebody suffering from a particular mental illness. I think the police should be schooled on that subject. And maybe they would learn to respect the mentally ill a little more.”
3.8.2.2. Communicating effectively. Participants discussed how police officers should be trained to communicate with people who have mental illness in a more respectful and effective manner. This included using supportive language, respecting confidentiality, and using verbal deescalation skills:
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could have been a sack of flour. … It's all just by the book … and I'm just nothing. I'm not a human being.”
3.8.2.4. Prioritizing non-violent responses. Several participants discussed the need for police officers to become more adept at using nonaggressive, non-violent approaches when dealing with situations involving people with mental illness. Many suggested that a police officer's response is a major factor that influences whether an interaction will escalate into aggression and violence: “Let's say the police get a call for violence, okay. So, ten out of ten times, that I've seen, they show up on the scene, and what do they do? They get violent. … That's hypocritical to me. It makes no sense to me.”
3.8.3. Connecting with the community Providing police officers with an opportunity to have direct contact with people coping well with their mental illness, as well as people with direct experience with police encounters, was also recommended by the participants: “Follow up with someone like me to see what I am like when I am well. Then they [the police] can learn more about mental illness and know how to handle people like me.”
3.8.4. Recognizing and rewarding positive police practice Some participants stated that, in addition to holding the police accountable for misconduct, police officers should be acknowledged for situations that have been handled in a positive and constructive manner: “There are police officers that just have reputations in the community as being more mentally health aware or whatever. … Really make sure that they get recognized for the efforts in change that they're trying to make. I think those people would be valuable resources in any training.”
3.8.5. Improving how police officers are selected and supported Participants' recommendations also focused on a range of human resource-related issues, such as ensuring that the ‘right’ officers get hired, supporting officers to cope with job-related stress, rewarding officers for professional development, and recognizing that some officers are not predisposed to engage effectively with people who have mental illness:
“Ask the person if they are under the care of a physician or psychiatrist. Are they on medication for a mood disorder? Be gentle, but ask questions. … Ask if there is any help they need. Tell them we all need to be safe, treat them with dignity.”
“Just fire the jerks! I mean, there are some people that just can't even be educated because they just come from a background of not understanding mental illness, and they will never come around. … You can't keep on people who are going to abuse people with mental illnesses.”
3.8.2.3. Treating people with compassion. Participants also indicated that police officers should learn to be more compassionate and respectful in dealing with situations involving people with mental illness. They indicated that police officers should be to be taught to adjust their response style when interacting with someone who has a mental illness, especially in the context of a mental health crisis:
3.8.6. Recognizing the role of peer influence A small group of participants indicated that certain police officers are positive role models and should be placed in positions to influence how their peers interact with people who have mental illness:
“Sometimes be more human, not so policy driven. And I don't just mean handcuffs, I mean sometimes I'm just transported and … I
“In general, I don't think they [the police] are prepared for interactions with us. But, there are remarkable exceptions. Find those officers and have them train the other officers.”
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
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3.8.7. Increasing accountability Improving accountability and independent oversight of the police was identified as an important means toward improving how people with mental illness perceive and interact with the police: “I don't think the police, should be policing the police. … I think that that's ridiculous. I think that's counterproductive. I think it's just extremely untransparent [sic]. … I just don't think it makes any sense.”
3.8.8. Involving health professionals A final recommendation raised by a number of participants focused on ensuring that health professionals were actively involved in mental health-related police contacts: “Ensure ambulance and medical personnel are present for mental illness incidents and not just police. Ensure there is a mental health advocate present during interactions with people suffering mental illness.”
4. Discussion Few studies have explored the viewpoints of people with mental illness regarding their interactions with police. One of the study objectives was to learn how often, and under what circumstances, people with mental illness interact with the police. Consistent with prior research in this area (Crocker, Hartford, & Heslop, 2009; Finlayson, Greenland, Dawson, Blam, & Pittman, 1983; Teplin, 1985; Watson et al., 2010), interactions with police were common among participants and occurred under a diverse range of situations. Many of our participants initiated contact with the police for reasons unrelated to perpetrating a crime (e.g., requesting assistance as a victim of crime or for mental health reasons) and most of their interactions were resolved by means other than apprehension and/or arrest. One area of concern was the finding that police use of force was a prevalent experience among the participants. Approximately three-quarters of participants reported being handcuffed by the police, injury was sustained by more than a quarter of participants, and a third of participants perceived that they had been subjected to excessive police force. Such experiences have the potential to exert a substantial negative influence on how people perceive the police. Another study objective was to understand how people with mental illness perceive the police. Perceptions about lifetime police interactions tended to be more positive than negative, but displayed variability overall, which is consistent with other research (Jones & Mason, 2002; Watson et al., 2008). Additionally, participants whose most recent contact with the police was in the context of a mental health crisis indicated that they were treated in a procedurally fair manner by the police officer(s), and were largely satisfied with how the situation was handled. Despite prevalent experiences of police force, the overall results suggested that the majority of participants held positive attitudes toward their interactions with police. Such a finding challenges the asymmetry hypothesis, which posits that people have a tendency to ascribe more weight to negative personal experiences and this, in turn, affects their attitudes and perceptions toward the police (Skogan, 2006). Indeed, ratings of procedural justice and satisfaction regarding the most recent police interaction were mostly positive and were strongly correlated. This indicates that teaching procedural justice related skills (e.g., active listening, perspective taking, non-stigmatizing attitudes) to officers would be a fruitful strategy for improving interactions with people who have mental illness (Watson & Angell, 2007). A final goal of our study was to obtain suggestions from people with mental illness regarding how perceptions of, and interactions with, the police can be improved. Almost half of the participants indicated that their most recent interaction with the police could have been handled
better. The importance of police training emerged as a consistent theme, with almost all participants indicating that police officers need to be better trained to handle situations involving people with mental illness. The participants' qualitative responses indicated that mental health-related training would better prepare police officers to manage situations using non-violent methods, which ultimately serves to protect the safety of the officers as well as people with mental illness. Core features of the training curriculum suggested by the participants focused on communication skills, symptoms and behaviors related to mental illness, compassionate treatment, and non-violent interventions. These suggestions align with the findings of another study in which the participants made the following recommendations to the police: (a) allow people with mental illness an opportunity to explain themselves, (b) treat them like human beings, (c) be patient, (d) respond in a calm manner, (e) recognize symptoms or ask about mental illness, and (f) complete special training to help them respond to people with mental illness more effectively and keep situations from escalating (Watson et al., 2008). Beyond providing the police with appropriate information and training, our participants also suggested several other innovative strategies to improve interactions between the police and people with mental illness, such as rewarding positive police practices and increasing opportunities for positive interpersonal contact between police officers and people with mental illness. Research indicates that facilitating direct social contact between the police and people who are recovering from mental illness is one of the most effective ways to reduce stigma (Dalky, in press; Thornicroft, Brohan, Kassam, & Lewis-Holmes, 2008). 4.1. Limitations There are some important caveats for the interpretation of the study findings, including the sample and the research materials. With regard to the sample, participants self-identified for inclusion in the study. Consequently, self-selection bias may negatively impact the validity of the findings. Decision-making among potential participants may have been associated with germane factors, such as degree of trust in authority figures. Other participant characteristics may have introduced further limitations, such as the underrepresentation of people who were younger or from ethnically diverse communities. Additionally, the eligibility criteria restricted study participation to people with particular primary psychiatric diagnoses (i.e., schizophrenia, schizoaffective disorder, bipolar disorder) and, therefore, the findings do not necessarily reflect the perspectives and experiences of people with other mental illnesses (e.g., depression, anxiety, substance use disorder). The study may also be limited by the subjective, self-report nature of the data collection. None of the information gathered was corroborated; therefore, some information may be inaccurate or biased. Informal feedback suggested, however, that employing peer researchers reduced power differentials, and facilitated trust and rapport between interviewer and participant, thereby promoting honest disclosure of sensitive information. 4.2. Future work The present study raised additional research questions. One topic that warrants further examination is the degree to which mental health training improves police officers' attitudes and behaviors, and ultimately, the experiences of people with mental illness. Preliminary evidence suggests that it does (Bahora, Hanafi, Chien, & Compton, 2008). Additionally, in-depth analyses of the processes involved in a single type of police interaction, such as a mental health crisis, would contribute to a better understanding of the dynamic relationships between a person with mental illness, the police officer(s), and the environment. Such a study would provide insight into factors that influence decision making among police officers and people with mental illness. Further research is also needed to understand how perceptions of procedural justice are influenced by personal, situational, and contextual factors.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx
5. Conclusion Although this is only the third study to address this issue and the first conducted in Canada, the findings paint a balanced and relatively positive picture of police interactions from the perspective of people with mental illness. The results also highlight the complexity and variability in how people with mental illness perceive and interact with the police. Ensuring that procedural elements of police interactions are transparently just and fair may be one of the most important paths toward improving the experiences of people with mental illness. Prioritizing such an approach has the potential to build and nurture mutual respect, understanding, and collaboration. Additionally, these findings provide valuable insight to police trainers and police practitioners, emphasizing the importance and critical impact of communications skills while encountering people with mental illness. A procedurally skilful police officer who uses minimal force has an increased likelihood of obtaining a desired objective and enhancing the overall outcome of an interaction. Competing interests None. Acknowledgments and disclosures Financial support for this study was provided by the Mental Health Commission of Canada and BC Mental Health & Addiction Services. Sarah Desmarais was supported by Award Number P30DA028807 from the National Institute on Drug Abuse. The authors are grateful to the skilful assistance of Caroline Greaves, Michelle Pritchard, Sara Lapsley, and Michael Crain. We are indebted to the individuals who gave their time to participate in this study. References Bahora, M., Hanafi, S., Chien, V. H., & Compton, M. T. (2008). Preliminary evidence of effects of crisis intervention team training on self-efficacy and social distance. Administration and Policy in Mental Health, 35, 159–167. Bloom, J.D., Rogers, J. L., Manson, S. M., & Williams, M. H. (1986). Lifetime police contacts of discharged psychiatric security review board clients. International Journal of Law and Psychiatry, 8, 189–202. Borum, R., Swanson, J., Swartz, M., & Hiday, V. (1997). Substance abuse, violent behavior, and police encounters among persons with severe mental disorder. Journal of Contemporary Criminal Justice, 13, 236–250. Cascardi, M., Poythress, N. G., & Hall, A. (2000). Procedural justice in the context of civil commitment: An analogue study. Behavioral Sciences & the Law, 18, 731–740. Cotton, D., & Coleman, T. G. (2010). Canadian police agencies and their interactions with persons with a mental illness: A systems approach. Police Practice and Research: An International Journal, 11, 301–314. Crocker, A. G., Hartford, K., & Heslop, L. (2009). Gender differences in police encounters among persons with and without serious mental illness. Psychiatric Services, 60, 86–93. Dalky, H. F. (2012). Mental illness stigma reduction interventions: Review of intervention trials. Western Journal of Nursing Research, 34(2001), 520–547.
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Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
Contents lists available at ScienceDirect
International Journal of Law and Psychiatry
Perceptions and experiences of people with mental illness regarding their interactions with police James D. Livingston a,⁎, Sarah L. Desmarais b, Simon Verdun-Jones c, Richard Parent c, Erin Michalak d, Johann Brink d,e a
Department of Sociology & Criminology, Saint Mary's University, Nova Scotia, Canada Department of Psychology, North Carolina State University, North Carolina, USA School of Criminology, Simon Fraser University, British Columbia, Canada d Department of Psychiatry, University of British Columbia, British Columbia, Canada e Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, British Columbia, Canada b c
a r t i c l e
i n f o
Available online xxxx Keywords: Police Mental Illness Perceived Procedural Justice Mixed method
a b s t r a c t This study examined the perceptions and lived experiences of people with mental illness in relation to their interactions with the police. A community-based participatory research approach was used and a procedural justice theoretical perspective guided the study. In-depth, semi-structured interviews were conducted by peer researchers with 60 people with mental illness who had interacted with the police and were living in Metro Vancouver, Canada. Among the study participants, contact with the police was frequent and occurred under a diverse range of circumstances. The majority of participants perceived being treated in a procedurally just manner by the police officer(s) who were involved in their most recent interaction. Almost three-quarters (n = 43, 72%) of participants were generally satisfied with how the police officer(s) had handled their most recent interaction. The slight majority of participants (n = 30, 51%) rated their previous contacts with the police as a positive experience overall, with 32% (n = 19) indicating that their previous interactions with the police were negative life experiences. The findings paint a more balanced picture than that which is often portrayed by the media. Emphasizing a procedural justice framework for police handling of situations involving people with mental illness is a vital step toward improving how these interactions are experienced and perceived. © 2014 Published by Elsevier Ltd.
1. Introduction In contrast with popular media depictions (Sieff, 2003; Stout, Villegas, & Jennings, 2004), most people with mental illness do not commit criminal or violent acts; however, research suggests that contact with the police is common among this population (Bloom, Rogers, Manson, & Williams, 1986; Gelberg, Linn, & Leake, 1988; Holcomb & Ahr, 1988; Theriot & Segal, 2005). Explanations for the occurrence of these interactions are complex, but generally focus on clinical risk factors, such as co-occurring substance use problems and treatment non-adherence, as well as social and systemic factors, including deinstitutionalization policies, homelessness, poverty, community disorganization, poorly funded and fragmented community-based services, hospital emergency room bed pressures, overly restrictive civil commitment criteria, intolerance of social disorder, and criminal law reforms (Borum, Swanson, Swartz, & Hiday, 1997; Cotton & Coleman, 2010;
⁎ Corresponding author at: 923 Robie Street, Halifax, Nova Scotia, B3H3C3, Canada. Tel.: +1 902 491 6258; fax: +1 902 520 5121. E-mail address: [email protected] (J.D. Livingston).
Lamb, Weinberger, & Gross, 2004; Silver, 2006; Van Dorn, Volavka, & Johnson, in press). Furthermore, the police play a pivotal role in the application of both civil commitment legislation and criminal procedure on account of their mandated role in society, contributing to the frequency of encounters with people who have mental illness (Cotton & Coleman, 2010). Increasingly, police officers have assumed expanded functions of maintaining social order, which include responding to mental health crises (Lamb et al., 2004; Patch & Arrigo, 1999). As a result, they can significantly influence the lives of people with mental illness. Police are often the principal first responders to situations involving people with mental illness, which has earned them the monikers “de facto mental health service providers” (Patch & Arrigo, 1999) and “psychiatrists in blue” (Menzies, 1987). In many situations, police officers have considerable discretion to use a range of informal or formal interventions, thereby assuming a gatekeeper function to the mental health and criminal justice systems (Lamb, Weinberger, & DeCuir, 2002; Patch & Arrigo, 1999; Watson, Corrigan, & Ottati, 2004). Many factors affect the subjective experience of interacting with the police. In addition to the purpose or outcome of the interaction, procedural justice theory suggests that the perceived fairness with which
http://dx.doi.org/10.1016/j.ijlp.2014.02.003 0160-2527/© 2014 Published by Elsevier Ltd.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
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people are treated during police interactions influences their subjective experience of the encounter (Cascardi, Poythress, & Hall, 2000; Wales, Hiday, & Ray, 2010; Watson & Angell, 2007). Accordingly, the degree to which police officers treat people with dignity and respect, provide them with opportunities to present their own side of the story, and appear concerned for their welfare is likely to affect the nature and perception of these encounters (Watson & Angell, 2007). This is consistent with research showing that people with mental illness who feel powerless and coerced tend to experience higher levels of internalized stigma (Link, Castille, & Stuber, 2008). Internationally, police services are investing considerable resources in initiatives, such as specialized police response programs and training, designed to improve the manner in which officers respond to and interact with people who have mental illness (Cotton & Coleman, 2010; Parent, 2007; Price, 2005; Steadman, Deane, Borum, & Morrissey, 2000; Tucker, Van Hasselt, & Russell, 2008). Many of these efforts have been triggered by inquiries into fatal encounters involving the police and people with mental illness. A significant limitation of these important initiatives is that they have not been systematically informed by the perspectives and experiences of people who live with mental illness, likely due in part to the dearth of research in this area. We are aware of only two systematic studies that have examined in-depth the perceptions and experiences of people with mental illness regarding their encounters with the police: the first involved interviews with 26 community mental health service users (Watson, Angell, Morabito, & Robinson, 2008) and the second was comprised of interviews with 16 individuals with psychotic illnesses who had been detained by the police (Jones & Mason, 2002). Together, findings of these studies indicate that perceptions vary and are heavily influenced by the attitudes and behaviors of police officers; however, the generalizability of results derived from such small samples is questionable and further research is required. Using a community-based research approach and guided by procedural justice theory, the present study contributes to this body of knowledge by examining the perceptions and experiences of people with mental illness in relation to their interactions with the police. 2. Method The study protocols were approved by the research ethics committees of the University of British Columbia, Simon Fraser University, and relevant health agencies. 2.1. Community-based participatory research (CBPR) approach The present study focused on sensitive issues involving power differentials among a marginalized population. As such, we employed an inclusive and collaborative research strategy. CBPR describes a way of engaging community members in research; their involvement is not limited to the role of research subject, but rather they are actively engaged in all stages of the research process and are involved in cocreating the findings (Minkler & Wallerstein, 2008). Accordingly, people with mental illness were involved in multiple levels of this project: the research team included people who have lived experience with mental illness, the research materials were developed in consultation with people who have mental illness, and the data collection process was led and performed by peer researchers. 2.2. Participants From April to December 2010, 60 participants were recruited from mental health centers and agencies in Metro Vancouver, Canada. Study inclusion criteria were: (a) current diagnosis of schizophrenia, schizoaffective disorder, other psychosis, or bipolar disorder (selfreported); (b) previous contact with police (self-reported); (c) age
19 years or older; (d) able to speak and understand English; and (e) cognitively capable of providing research consent. 2.3. Materials A semi-structured interview guide was developed in consultation with content experts, including people with mental illness who had previous contact with the police. The guide contained detailed questions regarding participants' most recent police encounter, with several items drawn from the Police Contact Experience Scale (PCES) (Watson, Angell, Vidalon, & Davis, 2010). The PCES is a standardized measure for assessing situational, procedural, and interpersonal aspects of interactions between people with mental illness and the police. The PCES includes a ten item perceived procedural justice (PPJ) subscale that assesses the extent to which someone believes they have been treated in a procedurally just manner by the police. The PCES also contains a five item perceived coercion (PC) subscale that measures subjective experiences of coercion and a four item satisfaction subscale that assesses the degree to which participants felt that their situation was handled appropriately by police. Additionally, a three item outcome favorability subscale evaluates participants' perspectives regarding the disposition of a police interaction. All items are rated on a 4-point scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (4). Higher scores on the subscales indicate higher levels of the corresponding construct (e.g., procedural justice, coercion). Participants' lifetime police interactions were also queried, including frequency and types of contact. In addition, participants were asked to indicate whether their previous interactions were perceived as positive or negative experiences overall, on a 5-point scale ranging from ‘very negative’ (1) to ‘very positive’ (5). Finally, participants were asked to identify ways to improve how the police handle situations involving people with mental illness. 2.4. Procedures A range of recruitment strategies was used, including distributing advertisements via email, posters, websites, e-newsletters, and at consumer events. The advertisements provided a brief study description and instructions for contacting the research team. Potential participants were screened for inclusion by a graduate-level research assistant either in person or by telephone. The consent form was reviewed with the potential participant and questions answered. Eligible individuals were booked for an appointment during which a peer researcher obtained written informed consent and proceeded with the interview. Interviews were conducted in private, lasting approximately 60 min. Digital recordings of the interviews were transcribed verbatim. Participants were paid $10 for their contributions. 3. Results 3.1. Participants Participant characteristics are summarized in Table 1. Women represented approximately one-third (n = 19, 32%) of the sample. Over three-quarters (n = 47, 78%) self-identified as White/Caucasian. The average age was 45.2 years (SD = 10.7); however, the youngest age group (19 to 29 years) was only comprised of four participants. Most (n = 54, 90%) had a household income of less than $25,000 CDN and most (n = 38, 63%) had experienced homelessness. More than half (n = 33, 55%) had a history of problematic substance use. Past year victimization was reported by 37% (n = 22) of participants. Almost all participants (n = 56, 93%) had been the victim of a crime during their lifetime, including 72% (n = 49) who had been violently victimized. Thirteen percent (n = 8) perpetrated a criminal act within the past year. The majority (n = 44, 73%) reported perpetrating a crime during their lifetime, with 53% (n = 32) of participants
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx Table 1 Participant characteristics. Characteristics Gender Male Female Age, in years Mean ± SD Ethnicity White/Caucasian Aboriginal Asian Other/multiple Country of birth Canada Other Primary language English Other Employment status Paid employment Not employed Household income b$25,000 CDN N$25,000 CDN Education level Did not complete high school/GED Completed high school/GED History of homelessness Lifetime, yes Past year, yes Primary psychiatric diagnosis Schizophrenia Schizoaffective disorder Bipolar disorder Other psychotic disorder History of problematic substance use Yes No History of involuntary psychiatric hospitalization Yes No
3
Table 2 Nature of interactions with the police. n
%
41 19
68 32
57
45.2 ± 10.7
47 5 3 5
78 8 5 8
49 11
82 18
53 7
88 12
29 31
48 52
one-third of participants (n = 21, 35%) interacted with the police in the context of mental health crises during their lifetime.
54 6
90 10
3.4. Use of force by police officers
16 44
27 73
38 9
63 15
20 15 20 5
33 25 33 8
33 27
55 45
46 11
81 19
committing violent crimes. Over their lifetime, just fewer than half (47%, n = 28) had been convicted of criminal offenses and 35% (n = 21) had been adjudicated ‘Not Criminally Responsible on account of a Mental Disorder’. 3.2. Number of interactions Numerous and recent contacts with the police were common. Onethird (n = 20, 33%) of participants had at least one police contact during the month prior to the interview. Two-thirds (n = 40, 67%) of participants interacted with the police in the past year, including 13% (n = 8) who had six or more encounters. The sample reported the following number of lifetime interactions with police: 1 contact (n = 1, 2%), 2 to 5 contacts (n = 10, 17%), 6 to 10 contacts (n = 17, 28%), 11 to 25 contacts (n = 10, 17%), and 26 or more contacts (n = 22, 37%).
Reasons
Casual or informal Street stop/check Committed a criminal offense Requested assistance as a victim of a crime Domestic dispute Requested assistance to report a crime Public disturbance Committed a violent criminal offense Requested assistance as a witness to a crime Mental health crisis Served with a warrant DUI or traffic violation
Lifetime contacts
Most recent contacts
n
Valid %
n
Valid %
45 41 38 33 32 25 24 22 21 21 20 17
75 68 64 55 53 42 40 37 35 35 33 28
5 11 11 11 6 7 7 4 3 17 4 3
8 18 18 18 10 12 12 7 5 28 7 5
During their lifetime, almost three-quarters (n = 43, 72%) of participants reported being handcuffed and 57% (n = 34) had been physically restrained by a police officer — often in the context of a mental health apprehension. More than a quarter (n = 17, 28%) of participants reported having ever been pushed or shoved by a police officer, while 17% (n = 10) had been punched or kicked by a police officer. Almost twothirds (n = 19, 32%) reported having had a weapon (e.g., baton, conductive energy device, firearm) pointed at them by a police officer and 8% (n = 15) had a police issued weapon used against them in their lifetime. A quarter (n = 15, 25%) had previously been involved in police interactions resulting in minor injury to the participant (not requiring medical attention), whereas 12% (n = 7) suffered serious injury (requiring medical attention). Thirty-seven percent (n = 22) of participants felt that the degree of force used by police during previous interactions had been excessive. 3.5. Outcomes of interactions Participants' most recent interactions with the police were primarily resolved through informal means, including the officer taking no action (n = 19, 32%), writing a report (n = 12, 20%), or giving a warning (n = 5, 8%). Police officers also provided assistance during many of the interactions, including taking the participant to hospital for medical (n = 7, 12%) or psychiatric (n = 9, 15%) treatment, referring them to a mental health agency (n = 4, 7%), or providing other forms of assistance (e.g., providing a ride home) (n = 6, 10%). Fifteen percent (n = 9) of participants' most recent interactions resulted in apprehension or arrest (but not taken to hospital). During their lifetime, the vast majority of participants (n = 54, 90%) had been transported (e.g., to hospital or jail) by the police and 77% (n = 46) had been apprehended/arrested.
3.3. Nature of interactions 3.6. Perceptions of most recent interaction As summarized in Table 2, a diverse range of circumstances brought participants into contact with the police. Participants' most recent interaction with the police was most likely to involve a mental health crisis (n = 17, 28%) and least likely to involve a casual or informal encounter (n = 5, 8%). During their lifetime, most participants interacted with the police for reasons that included casual or informal encounters (n = 45, 75%), street stops and checks (n = 41, 68%), being suspected of committing a criminal offense (n = 38, 64%), requesting assistance as a victim of crime (n = 33, 55%), and domestic disputes (n = 32, 53%). Approximately
Ratings on PCES items pertaining to perceived procedural justice, perceived coercion, satisfaction, and outcome favorability are summarized in Table 3. The majority of participants perceived that they had been treated in a procedurally just and fair manner by the police officer(s) who were involved in their most recent interaction. For example, 88% (n = 52) indicated that they were treated humanely and 85% (n = 51) felt treated with respect. Fewer participants (n = 29, 52%) provided favorable ratings regarding the officers' level of concern toward understanding their needs.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
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Table 3 Perceptions about most recent interaction with the police. Police Contact Experience Scale
Mean ± SD
Perceived procedural justice (α = 0.94) The officer(s) treated me like a human being. The officer(s) were just doing their job. The officer(s) gave me enough time to do what they asked. The officer(s) treated me respectfully. The officer(s) tried to do what they thought was the best for me. I am satisfied with the way the officer(s) dealt with the situation. The officer(s) seemed genuinely concerned about me as a person. The officer(s) took the time to listen and understand my situation. The officer(s) went out of his/her way to be helpful. The officer(s) was concerned about understanding what I needed. Perceived coercion (α = 0.89) I had a lot of control over how the situation was resolved.c I had more influence than anyone else.c I felt free to do what I wanted.c I had a say in how the situation was resolved.c I felt free to say what I wanted.c Satisfaction (α = 0.91) The officer(s) generally did a good job dealing with my situation. I was generally satisfied with the way the officer(s) handled my situation. I was helped by what the officer(s) did. I was helped by what the officer(s) said. Outcome favorability (α = 0.87) The interaction with the officer was resolved the way I wanted it to be. The outcome of the situation with the police was better than I expected. The outcome I received was favorable. a b c
2.93 3.15 3.07 3.07 3.03 2.94 2.93 2.78 2.85 2.81 2.57 2.56 2.78 2.76 2.64 2.58 2.12 2.83 2.97 2.83 2.80 2.71 2.79 2.85 2.75 2.78
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.59 0.67 0.67 0.68 0.74 0.74 0.86 0.77 0.83 0.85 0.76 0.71 0.83 0.80 0.90 0.87 0.85 0.70 0.72 0.85 0.81 0.80 0.71 0.78 0.83 0.82
Disagreea
Agreeb
n
Valid %
n
Valid %
7 9 9 9 14 14 17 17 21 27
13 15 16 15 26 24 29 29 36 48
52 50 48 51 40 44 42 42 37 29
88 85 84 85 74 76 71 71 64 52
39 40 36 31 16
66 68 61 54 27
20 19 23 26 44
34 32 39 46 73
12 17 16 23
20 28 27 40
47 43 43 35
80 72 73 60
15 20 19
25 35 33
44 37 39
76 68 67
Includes ‘strongly disagree’ (1) and ‘disagree’ (2) response options. Includes ‘agree’ (3) and ‘strongly agree’ (4) response options. Reverse coded items.
Perceived coercion was prevalent among participants' most recent police interaction. For instance, 66% (n = 39) did not feel that they had ‘a lot of control’ over the resolution of the situation. In contrast, almost three-quarters (n = 44, 73%) of participants felt free to verbally express themselves during their most recent police interaction. Eighty percent (n = 47) of participants indicated that the police officer(s) did a good job and 72% (n = 43) were generally satisfied with how their most recent situation was handled. Noteworthy is that the majority of participants (n = 44, 76%) also indicated that the police interaction was resolved the way they wanted it to be, with 68% (n = 37) reporting that the outcome was better than expected. Since many police response programs and training have focused on mental health crises, analyses were performed to compare the perceptions of participants whose most recent police interactions were (n = 17) and were not (n = 43) in the context of a mental health crisis. Ratings revealed no significant differences perceived procedural justice, t(58) = 0.73, P N .05, perceived coercion, t(58) = 0.41, P N .05, satisfaction, t(58) = 1.15, P N .05, and outcome favorability, t(58) = 1.09, P N .05. As summarized in Table 4, the four PCES subscales were significantly correlated. Participants' level of satisfaction was strongly correlated with perceptions of procedural justice (r = 0.88, P b 0.001), outcome favorability (r = 0.75, P b 0.001), and perceived coercion (r = −0.67,
P b 0.001). Perceived procedural justice was strongly associated with perceived coercion (r = − 0.77, P b 0.001) and outcome favorability (r = 0.78, P b 0.001). This demonstrates the interrelatedness of processes (i.e., procedural justice, coercion) and outcomes (i.e., favorability, satisfaction) in shaping participants' perceptions of their most recent police interactions.
3.7. Perceptions of lifetime interactions Half of participants (n = 30, 51%) rated their previous contacts with the police as an overall positive experience, with 32% (n = 19) indicating that these lifetime experiences were ‘very positive’. One-third (n = 19, 32%) of participants perceived their interactions with the police as a negative life experience, with 19% (n = 11) rating the experiences as ‘very negative’. Seventeen percent (n = 10) felt that their previous interactions were neither positive nor negative life experiences. Participants' overall ratings of police interactions during their lifetime were moderately correlated with PCES subscale ratings regarding their most recent interaction: perceived procedural justice (r = 0.56, P b 0.001), perceived coercion (r = − 0.55, P b 0.001), satisfaction (r = 0.57, P b 0.001) and outcome favorability (r = 0.53, P b 0.001). This suggests that participants' impressions of previous interactions with the police were linked with perceptions of recent encounters.
3.8. Improving interactions with the police Table 4 Perceptions about most recent interaction with the police. Police Contact Experience Scale
PPJ
PC
S
OF
Perceived procedural justice (PPJ) Perceived coercion (PC) Satisfaction (S) Outcome favorability (OF)
–⁎ −0.77⁎⁎⁎ 0.88⁎⁎⁎ 0.78⁎⁎⁎
−0.77⁎⁎⁎ –⁎⁎ −0.67⁎⁎⁎ −0.61⁎⁎⁎
0.88⁎⁎⁎ −0.67⁎⁎⁎ – 0.75⁎⁎⁎
0.67⁎⁎⁎ −0.54⁎⁎⁎ 0.71⁎⁎⁎ –
⁎⁎⁎ p b 0.001 (2 tailed).
Qualitative data pertaining to participants' recommendations for improving interactions with the police were analyzed by the principal author using a qualitative description approach (Neergaard, Olesen, Andersen, & Sondergaard, 2009). The data was coded, and then sorted and combined based on similar patterns and themes. This section describes the eight major themes, with selected quotes, that emerged from the data.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx
3.8.1. Police access to information Almost all participants indicated that it would be helpful for police officers to have access to personal information about a person with mental illness prior to arriving on scene, such as whether they have a history of suicide or the nature of the mental health problem. One participant indicated the following reason why such information would be helpful to the police: “So they [the police] go into a situation and know how to handle the person, how to speak to the person, know a bit about his background, so they don't offend them or set them off, or how to get the situation under control.” Although participants were generally supportive of the police having access to mental health-related information, they also expressed the need for proper training for police to handle such information in an appropriate manner: “If the system is gonna make the effort to properly train and support people with mental illness living in the community, then I'm all for them [the police] having access to that information. But if they're just gonna continue the … hit first and talk later … I'm not so into giving out that information.” 3.8.2. Police education and training The majority of participants indicated that police training and education were important ways to improve interactions between the police and people with mental illness. They identified the following four critical elements for police training programs. 3.8.2.1. Understanding mental illness and its effects. Many participants spoke about previous police interactions in which the officer(s) did not appear to understand the basics of mental illness, including how it might affect a person's cognition and behavior. The participants felt that increasing knowledge about mental illness, including how it is experienced and how it affects an individual, would improve the attitudes and behaviors of police officers: “I really think there should be some effort made in teaching them [the police] at least the basics of the types of mental illness and what can be expected from somebody suffering from a particular mental illness. I think the police should be schooled on that subject. And maybe they would learn to respect the mentally ill a little more.”
3.8.2.2. Communicating effectively. Participants discussed how police officers should be trained to communicate with people who have mental illness in a more respectful and effective manner. This included using supportive language, respecting confidentiality, and using verbal deescalation skills:
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could have been a sack of flour. … It's all just by the book … and I'm just nothing. I'm not a human being.”
3.8.2.4. Prioritizing non-violent responses. Several participants discussed the need for police officers to become more adept at using nonaggressive, non-violent approaches when dealing with situations involving people with mental illness. Many suggested that a police officer's response is a major factor that influences whether an interaction will escalate into aggression and violence: “Let's say the police get a call for violence, okay. So, ten out of ten times, that I've seen, they show up on the scene, and what do they do? They get violent. … That's hypocritical to me. It makes no sense to me.”
3.8.3. Connecting with the community Providing police officers with an opportunity to have direct contact with people coping well with their mental illness, as well as people with direct experience with police encounters, was also recommended by the participants: “Follow up with someone like me to see what I am like when I am well. Then they [the police] can learn more about mental illness and know how to handle people like me.”
3.8.4. Recognizing and rewarding positive police practice Some participants stated that, in addition to holding the police accountable for misconduct, police officers should be acknowledged for situations that have been handled in a positive and constructive manner: “There are police officers that just have reputations in the community as being more mentally health aware or whatever. … Really make sure that they get recognized for the efforts in change that they're trying to make. I think those people would be valuable resources in any training.”
3.8.5. Improving how police officers are selected and supported Participants' recommendations also focused on a range of human resource-related issues, such as ensuring that the ‘right’ officers get hired, supporting officers to cope with job-related stress, rewarding officers for professional development, and recognizing that some officers are not predisposed to engage effectively with people who have mental illness:
“Ask the person if they are under the care of a physician or psychiatrist. Are they on medication for a mood disorder? Be gentle, but ask questions. … Ask if there is any help they need. Tell them we all need to be safe, treat them with dignity.”
“Just fire the jerks! I mean, there are some people that just can't even be educated because they just come from a background of not understanding mental illness, and they will never come around. … You can't keep on people who are going to abuse people with mental illnesses.”
3.8.2.3. Treating people with compassion. Participants also indicated that police officers should learn to be more compassionate and respectful in dealing with situations involving people with mental illness. They indicated that police officers should be to be taught to adjust their response style when interacting with someone who has a mental illness, especially in the context of a mental health crisis:
3.8.6. Recognizing the role of peer influence A small group of participants indicated that certain police officers are positive role models and should be placed in positions to influence how their peers interact with people who have mental illness:
“Sometimes be more human, not so policy driven. And I don't just mean handcuffs, I mean sometimes I'm just transported and … I
“In general, I don't think they [the police] are prepared for interactions with us. But, there are remarkable exceptions. Find those officers and have them train the other officers.”
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
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J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx
3.8.7. Increasing accountability Improving accountability and independent oversight of the police was identified as an important means toward improving how people with mental illness perceive and interact with the police: “I don't think the police, should be policing the police. … I think that that's ridiculous. I think that's counterproductive. I think it's just extremely untransparent [sic]. … I just don't think it makes any sense.”
3.8.8. Involving health professionals A final recommendation raised by a number of participants focused on ensuring that health professionals were actively involved in mental health-related police contacts: “Ensure ambulance and medical personnel are present for mental illness incidents and not just police. Ensure there is a mental health advocate present during interactions with people suffering mental illness.”
4. Discussion Few studies have explored the viewpoints of people with mental illness regarding their interactions with police. One of the study objectives was to learn how often, and under what circumstances, people with mental illness interact with the police. Consistent with prior research in this area (Crocker, Hartford, & Heslop, 2009; Finlayson, Greenland, Dawson, Blam, & Pittman, 1983; Teplin, 1985; Watson et al., 2010), interactions with police were common among participants and occurred under a diverse range of situations. Many of our participants initiated contact with the police for reasons unrelated to perpetrating a crime (e.g., requesting assistance as a victim of crime or for mental health reasons) and most of their interactions were resolved by means other than apprehension and/or arrest. One area of concern was the finding that police use of force was a prevalent experience among the participants. Approximately three-quarters of participants reported being handcuffed by the police, injury was sustained by more than a quarter of participants, and a third of participants perceived that they had been subjected to excessive police force. Such experiences have the potential to exert a substantial negative influence on how people perceive the police. Another study objective was to understand how people with mental illness perceive the police. Perceptions about lifetime police interactions tended to be more positive than negative, but displayed variability overall, which is consistent with other research (Jones & Mason, 2002; Watson et al., 2008). Additionally, participants whose most recent contact with the police was in the context of a mental health crisis indicated that they were treated in a procedurally fair manner by the police officer(s), and were largely satisfied with how the situation was handled. Despite prevalent experiences of police force, the overall results suggested that the majority of participants held positive attitudes toward their interactions with police. Such a finding challenges the asymmetry hypothesis, which posits that people have a tendency to ascribe more weight to negative personal experiences and this, in turn, affects their attitudes and perceptions toward the police (Skogan, 2006). Indeed, ratings of procedural justice and satisfaction regarding the most recent police interaction were mostly positive and were strongly correlated. This indicates that teaching procedural justice related skills (e.g., active listening, perspective taking, non-stigmatizing attitudes) to officers would be a fruitful strategy for improving interactions with people who have mental illness (Watson & Angell, 2007). A final goal of our study was to obtain suggestions from people with mental illness regarding how perceptions of, and interactions with, the police can be improved. Almost half of the participants indicated that their most recent interaction with the police could have been handled
better. The importance of police training emerged as a consistent theme, with almost all participants indicating that police officers need to be better trained to handle situations involving people with mental illness. The participants' qualitative responses indicated that mental health-related training would better prepare police officers to manage situations using non-violent methods, which ultimately serves to protect the safety of the officers as well as people with mental illness. Core features of the training curriculum suggested by the participants focused on communication skills, symptoms and behaviors related to mental illness, compassionate treatment, and non-violent interventions. These suggestions align with the findings of another study in which the participants made the following recommendations to the police: (a) allow people with mental illness an opportunity to explain themselves, (b) treat them like human beings, (c) be patient, (d) respond in a calm manner, (e) recognize symptoms or ask about mental illness, and (f) complete special training to help them respond to people with mental illness more effectively and keep situations from escalating (Watson et al., 2008). Beyond providing the police with appropriate information and training, our participants also suggested several other innovative strategies to improve interactions between the police and people with mental illness, such as rewarding positive police practices and increasing opportunities for positive interpersonal contact between police officers and people with mental illness. Research indicates that facilitating direct social contact between the police and people who are recovering from mental illness is one of the most effective ways to reduce stigma (Dalky, in press; Thornicroft, Brohan, Kassam, & Lewis-Holmes, 2008). 4.1. Limitations There are some important caveats for the interpretation of the study findings, including the sample and the research materials. With regard to the sample, participants self-identified for inclusion in the study. Consequently, self-selection bias may negatively impact the validity of the findings. Decision-making among potential participants may have been associated with germane factors, such as degree of trust in authority figures. Other participant characteristics may have introduced further limitations, such as the underrepresentation of people who were younger or from ethnically diverse communities. Additionally, the eligibility criteria restricted study participation to people with particular primary psychiatric diagnoses (i.e., schizophrenia, schizoaffective disorder, bipolar disorder) and, therefore, the findings do not necessarily reflect the perspectives and experiences of people with other mental illnesses (e.g., depression, anxiety, substance use disorder). The study may also be limited by the subjective, self-report nature of the data collection. None of the information gathered was corroborated; therefore, some information may be inaccurate or biased. Informal feedback suggested, however, that employing peer researchers reduced power differentials, and facilitated trust and rapport between interviewer and participant, thereby promoting honest disclosure of sensitive information. 4.2. Future work The present study raised additional research questions. One topic that warrants further examination is the degree to which mental health training improves police officers' attitudes and behaviors, and ultimately, the experiences of people with mental illness. Preliminary evidence suggests that it does (Bahora, Hanafi, Chien, & Compton, 2008). Additionally, in-depth analyses of the processes involved in a single type of police interaction, such as a mental health crisis, would contribute to a better understanding of the dynamic relationships between a person with mental illness, the police officer(s), and the environment. Such a study would provide insight into factors that influence decision making among police officers and people with mental illness. Further research is also needed to understand how perceptions of procedural justice are influenced by personal, situational, and contextual factors.
Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
J.D. Livingston et al. / International Journal of Law and Psychiatry xxx (2014) xxx–xxx
5. Conclusion Although this is only the third study to address this issue and the first conducted in Canada, the findings paint a balanced and relatively positive picture of police interactions from the perspective of people with mental illness. The results also highlight the complexity and variability in how people with mental illness perceive and interact with the police. Ensuring that procedural elements of police interactions are transparently just and fair may be one of the most important paths toward improving the experiences of people with mental illness. Prioritizing such an approach has the potential to build and nurture mutual respect, understanding, and collaboration. Additionally, these findings provide valuable insight to police trainers and police practitioners, emphasizing the importance and critical impact of communications skills while encountering people with mental illness. A procedurally skilful police officer who uses minimal force has an increased likelihood of obtaining a desired objective and enhancing the overall outcome of an interaction. Competing interests None. Acknowledgments and disclosures Financial support for this study was provided by the Mental Health Commission of Canada and BC Mental Health & Addiction Services. Sarah Desmarais was supported by Award Number P30DA028807 from the National Institute on Drug Abuse. The authors are grateful to the skilful assistance of Caroline Greaves, Michelle Pritchard, Sara Lapsley, and Michael Crain. We are indebted to the individuals who gave their time to participate in this study. References Bahora, M., Hanafi, S., Chien, V. H., & Compton, M. T. (2008). Preliminary evidence of effects of crisis intervention team training on self-efficacy and social distance. Administration and Policy in Mental Health, 35, 159–167. Bloom, J.D., Rogers, J. L., Manson, S. M., & Williams, M. H. (1986). Lifetime police contacts of discharged psychiatric security review board clients. International Journal of Law and Psychiatry, 8, 189–202. Borum, R., Swanson, J., Swartz, M., & Hiday, V. (1997). Substance abuse, violent behavior, and police encounters among persons with severe mental disorder. Journal of Contemporary Criminal Justice, 13, 236–250. Cascardi, M., Poythress, N. G., & Hall, A. (2000). Procedural justice in the context of civil commitment: An analogue study. Behavioral Sciences & the Law, 18, 731–740. Cotton, D., & Coleman, T. G. (2010). Canadian police agencies and their interactions with persons with a mental illness: A systems approach. Police Practice and Research: An International Journal, 11, 301–314. Crocker, A. G., Hartford, K., & Heslop, L. (2009). Gender differences in police encounters among persons with and without serious mental illness. Psychiatric Services, 60, 86–93. Dalky, H. F. (2012). Mental illness stigma reduction interventions: Review of intervention trials. Western Journal of Nursing Research, 34(2001), 520–547.
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Please cite this article as: Livingston, J.D., et al., Perceptions and experiences of people with mental illness regarding their interactions with police, International Journal of Law and Psychiatry (2014), http://dx.doi.org/10.1016/j.ijlp.2014.02.003
