Police as a Community Mental Health Resource Robert Liberman, M.D.
ABSTRACT: In their pathways to the state mental hospital, almost 5o% of mentally ill patients and their families from Baltimore utilize the police as a community resource. To better understand why so many people use the police for help with mental problems, a comparison was made between first admission patients who used the police (N ---- 17) and those who used more conventional medical resources (N = 35). The results indicate that families decide to call the police because other, more appropriate, resources are not as accessible and will not offer services to recalcitrant patients. Until community mental health facilities develop more active evaluation and treatment programs for reluctant patients, the police will continue to serve a needed role in the care of the mentally ill.
The research reported here is addressed to the question: why do the police play such an important part in the care of the mentally ill? The prominence of the police as an agent in the handling of the mentally ill is found in most communities around the country (Glasscote, I966 ). Statewide surveys made in 1959 and ~963 in Indiana found that ~,z58 patients spent an average of seven days in jail during these two years. Most of them were in jail awaiting disposition to psychiatric treatment facilities. During 2964 in Virginia, just under 2,6oo persons were held in jail awaiting commitment to mental hospitals. A spokesman for the Texas Department of Mental Health estimates "that over half of the mentally ill patients in Texas who are awaiting diagnosis or commitment and are considered incompetent or dangerous spend at least a few days in a local jail." A similar situation is found in Florida where mentally ill people spend from ~o to ~4 days in jail awaiting competency hearings (Glasscote, 2966 ). The states mentioned here are presented as examples of a nationwide situation. In San Francisco the police referred one-fifth of the patients at the psychiatric service of the public hospital (Bittner, 2967). Hollingshead and Dr. Liberman is a psychiatrist associated with the Behavioral and Clinical Studies Research Center, St. Elizabeth's Hospital, NIMH, Washington, D.C. 2oo32. This study was performed when the author was associated with the Department of Mental Hygiene of The Johns Hopkins University School of Public Health and Hygiene. The research was financed by the Henry Strong Denison Fund for Medical Research. The author appreciates the encouragement of Professor Paul V. Lemkau and the technical assistance of Mrs. Mary Grotefend, R.N. Community Mental Health Journal, Vol, 5 (2), 1969
111
112
Community Mental Health Journal
Redlich (2958) found that in the lowest socioeconomic dass, more than half of psychotic patients are referred to psychiatric facilities b y the police. In Baltimore, the site of the present report, nearly half the residents admitted to state hospitals in 2957 came from police stations where they had been arrested and detained as prisoners (Maryland Association for Mental Health Report, 2962 ) . The m a j o r i t y of these patients either come to the police themselves or are apprehended following a complaint b y a family m e m b e r or relative. Most of the "police patients" in Baltimore are held in custody until a brief mental-status examination is performed b y two physicians, w h o are usually not psychiatrists. If deemed sufficiently ill, the person is committed to a state hospital from the station house. A l m o s t half of these patients, in 2957 , were kept behind bars for more than ~2 hours before being admitted to a hospital. The present research approaches the police-mental patient involvement f r o m the point of view of the patient and his family: w h y do some people take their behavior and psychological problems to the police while others turn to w h a t would appear to be more functionally appropriate medical and psychiatric facilities ? METHODS A comparison was undertaken between those white, first admission patients from Baltimore who used the police (N = I7) and those who used medical or psychiatric resources (N = 35) for entry into the state mental hospitals. Details of the sample population and the selection process are given in other publications (Liberman, 9965, 2967). Interviews were conducted with each patient and a key family member within one month of admission. From the initial interview with the patient and from the patient's record it was determined who was responsible for the decision to seek help from that community resource which led to the hospitalization. This person was defined as the decision-maker. For the police cases, ~6 of 27 decision-makers were close relatives of the patient; one patient came himself to a police station for help. Among the medicalpsychiatric cases, 22 of 35 decision-makers were relatives; the remainder were the patients. The interviews were semistructured and covered six areas which were conceptually relevant to the process of seeking help from community resources: (z) demographic background characteristics; (2) ways of recognizing and labelling the deviance (Schwartz, I957); (3) ways of dealing with the problem prior to obtaining formal, outside help; (4) immediate situational factors surrounding the decision to seek help from community resources; (5) influences on the actual decision-making process; (6) accessibility to and attitudes toward different community resources. In addition, detailed information was obtained from the patients and their relatives on the actual community resources used, leading to hospitalization. Because both patients and relatives were interviewed, data on the consensus between them could be ascertained for the variables above. The results of the study will be presented in terms of this multiple variable model of the pathway to the mental hospital taken by police and medical cases. RESULTS Some typical reactions of police patients to their experiences are presented here. My neighbors certainly wouldn't want to associate with me after seeing the police taking me away in a patrol wagon. It was a poor (sic) down, degrading thing to do. I'd be very embarrassed in church or anywhere.
Robert Liberman
113
The police came to our house and surprised me. My mother thought she was doing the right thing. It was terrible being taken away by the police, but I went willingly. Six policemen and a policewoman came and picked me up. They took me to the police station and I stayed in the bleak, awful cell for three hours. I felt shamed to my heart. I knew it wasn't the place for me ... it's a place for a criminal. I felt I was under judgment by the world. (Told by a patient's daughter.) They put her in a cell and she was screaming and climbing on the bars to see if we had left yet ... we had to go back there several times to calm her down. I spent one night and a day in the police station. It was unpleasant. . . . I couldn't sleep ... just sat on a bench and stared at the wall . . . . They put me in handcuffs for the trip to the hospital. How much damage is clone to the therapeutic process by the jailing of prospective patients is hard to say, but it obviously delays the onset of treatment and adds another trauma to the individual. Over 70% of the police patients claimed they would not again use the police if they had a choice, but over 90% of their relatives who actually made the decision to call the police said that they would do so again if the opportunity arose.
Background Factors: Police vs. Medical Cases The people who decided to call the police for help were significantly older than those who decided to use medical or psychiatric resources. However, the ages of the two groups of patients did not differ. Social class was determined arbitrarily for comparative purposes from education and rent. Individuals with both a high school education or more, and rent of $80 per month or more, were placed in the "upper" class (25% of the sample). Those with either a high school education or more, or rent of $80 per month or more, were considered "middle" class (40% of the sample). "Lower" class individuals had less than a high school education and paid less than $80 per month rent (35% of the sample). The police patients tended to come from the "lower" class (65%) while the medical patients more often belonged to the "middle" class (66%), which is significant at the .05 level. However, social class did not differentiate key family members or decision-makers in the police and medical groups. No differences between the two groups were found for marital status, sex, religion, church attendance, or residential mobility. The distribution of admission diagnoses given the patients in the police and medical groups is shown in Table 5. A significantly greater proportion of police patients were diagnosed as schizophrenic (all paranoid type) or as having personality disorders, whereas the medical patients were more often diagnosed as neurotic or depressed. The differences in diagnoses between the two groups parallel the differences in attitudes of the patients toward getting help as will be shown below.
Recognizing and Defining the Problem A striking difference between the police and medical patients is seen in their degree of willingness to define their problem as "mental" or psychiatric. Denial of mental illness is made by 94% of the police pa-
114
Community Mental Health Journal
TABLE I Admission diagnoses of police and medical cases to state hospital Diagnosis
Schizophrenia Personalitydisorder Neurosis Depression Involutional melancholia Total
Police cases % No.
Medical cases % No.
58 24 x2 6 o xoo
26 14 28 23 9 200
xo 4 2 x o x7
9 5 so 8 3 35
p ~ 0.05, chi square, for differencesbetweenpoliceand medicalcases in schizophreniaand personality disorders vs. neurosis and depression and involutionalmelancholia. tients but by only 29% of the medical patients. The relatives of the patients in these two groups did not show this difference. Over 9o% in both groups viewed the problem as "mental." Three indexes of tolerance for deviance were derived from the time elapsing between (~) recognition of the problem and defining it as "mental," (2) recognition of the problem and seeking help from the first community resource, and (3) defining the problem as "mental" and seeking help from the first community resource. No differences emerged between the police and medical cases on these indexes of tolerance for deviance, either for the patients or for their family members. Similarly, there was little or no difference between patients or family members of the two groups on such important variables as causation imputed to the illness, seriousness attributed to the illness, duration or acuteness of the problem, or patient-family member consensus on these variables. These findings contradict the assumption made by Hollingshead and Redlich (~958) that families who call the police for help with a disturbed member are unsophisticated in their perception and definition of the disturbed behavior, and more tolerant of deviance. The key members of the patient's family were asked whether they thought the patient was to blame for his problem or whether he was just a victim of circumstances beyond his control. The resulting moral judgment passed on the police patient was significantly negative, i.e., blameworthy, more often than for the medical patient. The attitude of the patient toward getting help--his readiness for help-as seen by the patient himself and by the key family member dearly differentiates police cases from medical cases. Tables 2 and 3 show that the police patients are significantly more reluctant to see a need for professional help and less willing to go voluntarily to the state mental hospital. There was marked consensus between the patients' stated attitudes in these matters and the attitudes ascribed to them by their key family members.
Robed Liberman
115
TABLE 2 Patients' definition of their illness or problem at the time of hospitalization
Definition
Police cases % No.
"Mental" or psychiatric Denial of "mental" label Total
6 94 2oo
(2) (26) 27
Medical cases % No. 7i 29 ~oo
(25) (2o) 35
p ~ 0.002, chi square, difference between police and medical cases. TABLE 3 Readiness for getting help from formal community resources
Patients' responses Never wanted help and didn't think it was necessary Knew help was necessary but didn't want to go for it Realized need for help and wanted or was persuaded to get help Total
Police cases % No.
Medical cases % No.
79
(12)
22
(4)
22
(2)
9
(3)
27 2oo
(3) 27
80
(28)
zoo
35
p
ABSTRACT: In their pathways to the state mental hospital, almost 5o% of mentally ill patients and their families from Baltimore utilize the police as a community resource. To better understand why so many people use the police for help with mental problems, a comparison was made between first admission patients who used the police (N ---- 17) and those who used more conventional medical resources (N = 35). The results indicate that families decide to call the police because other, more appropriate, resources are not as accessible and will not offer services to recalcitrant patients. Until community mental health facilities develop more active evaluation and treatment programs for reluctant patients, the police will continue to serve a needed role in the care of the mentally ill.
The research reported here is addressed to the question: why do the police play such an important part in the care of the mentally ill? The prominence of the police as an agent in the handling of the mentally ill is found in most communities around the country (Glasscote, I966 ). Statewide surveys made in 1959 and ~963 in Indiana found that ~,z58 patients spent an average of seven days in jail during these two years. Most of them were in jail awaiting disposition to psychiatric treatment facilities. During 2964 in Virginia, just under 2,6oo persons were held in jail awaiting commitment to mental hospitals. A spokesman for the Texas Department of Mental Health estimates "that over half of the mentally ill patients in Texas who are awaiting diagnosis or commitment and are considered incompetent or dangerous spend at least a few days in a local jail." A similar situation is found in Florida where mentally ill people spend from ~o to ~4 days in jail awaiting competency hearings (Glasscote, 2966 ). The states mentioned here are presented as examples of a nationwide situation. In San Francisco the police referred one-fifth of the patients at the psychiatric service of the public hospital (Bittner, 2967). Hollingshead and Dr. Liberman is a psychiatrist associated with the Behavioral and Clinical Studies Research Center, St. Elizabeth's Hospital, NIMH, Washington, D.C. 2oo32. This study was performed when the author was associated with the Department of Mental Hygiene of The Johns Hopkins University School of Public Health and Hygiene. The research was financed by the Henry Strong Denison Fund for Medical Research. The author appreciates the encouragement of Professor Paul V. Lemkau and the technical assistance of Mrs. Mary Grotefend, R.N. Community Mental Health Journal, Vol, 5 (2), 1969
111
112
Community Mental Health Journal
Redlich (2958) found that in the lowest socioeconomic dass, more than half of psychotic patients are referred to psychiatric facilities b y the police. In Baltimore, the site of the present report, nearly half the residents admitted to state hospitals in 2957 came from police stations where they had been arrested and detained as prisoners (Maryland Association for Mental Health Report, 2962 ) . The m a j o r i t y of these patients either come to the police themselves or are apprehended following a complaint b y a family m e m b e r or relative. Most of the "police patients" in Baltimore are held in custody until a brief mental-status examination is performed b y two physicians, w h o are usually not psychiatrists. If deemed sufficiently ill, the person is committed to a state hospital from the station house. A l m o s t half of these patients, in 2957 , were kept behind bars for more than ~2 hours before being admitted to a hospital. The present research approaches the police-mental patient involvement f r o m the point of view of the patient and his family: w h y do some people take their behavior and psychological problems to the police while others turn to w h a t would appear to be more functionally appropriate medical and psychiatric facilities ? METHODS A comparison was undertaken between those white, first admission patients from Baltimore who used the police (N = I7) and those who used medical or psychiatric resources (N = 35) for entry into the state mental hospitals. Details of the sample population and the selection process are given in other publications (Liberman, 9965, 2967). Interviews were conducted with each patient and a key family member within one month of admission. From the initial interview with the patient and from the patient's record it was determined who was responsible for the decision to seek help from that community resource which led to the hospitalization. This person was defined as the decision-maker. For the police cases, ~6 of 27 decision-makers were close relatives of the patient; one patient came himself to a police station for help. Among the medicalpsychiatric cases, 22 of 35 decision-makers were relatives; the remainder were the patients. The interviews were semistructured and covered six areas which were conceptually relevant to the process of seeking help from community resources: (z) demographic background characteristics; (2) ways of recognizing and labelling the deviance (Schwartz, I957); (3) ways of dealing with the problem prior to obtaining formal, outside help; (4) immediate situational factors surrounding the decision to seek help from community resources; (5) influences on the actual decision-making process; (6) accessibility to and attitudes toward different community resources. In addition, detailed information was obtained from the patients and their relatives on the actual community resources used, leading to hospitalization. Because both patients and relatives were interviewed, data on the consensus between them could be ascertained for the variables above. The results of the study will be presented in terms of this multiple variable model of the pathway to the mental hospital taken by police and medical cases. RESULTS Some typical reactions of police patients to their experiences are presented here. My neighbors certainly wouldn't want to associate with me after seeing the police taking me away in a patrol wagon. It was a poor (sic) down, degrading thing to do. I'd be very embarrassed in church or anywhere.
Robert Liberman
113
The police came to our house and surprised me. My mother thought she was doing the right thing. It was terrible being taken away by the police, but I went willingly. Six policemen and a policewoman came and picked me up. They took me to the police station and I stayed in the bleak, awful cell for three hours. I felt shamed to my heart. I knew it wasn't the place for me ... it's a place for a criminal. I felt I was under judgment by the world. (Told by a patient's daughter.) They put her in a cell and she was screaming and climbing on the bars to see if we had left yet ... we had to go back there several times to calm her down. I spent one night and a day in the police station. It was unpleasant. . . . I couldn't sleep ... just sat on a bench and stared at the wall . . . . They put me in handcuffs for the trip to the hospital. How much damage is clone to the therapeutic process by the jailing of prospective patients is hard to say, but it obviously delays the onset of treatment and adds another trauma to the individual. Over 70% of the police patients claimed they would not again use the police if they had a choice, but over 90% of their relatives who actually made the decision to call the police said that they would do so again if the opportunity arose.
Background Factors: Police vs. Medical Cases The people who decided to call the police for help were significantly older than those who decided to use medical or psychiatric resources. However, the ages of the two groups of patients did not differ. Social class was determined arbitrarily for comparative purposes from education and rent. Individuals with both a high school education or more, and rent of $80 per month or more, were placed in the "upper" class (25% of the sample). Those with either a high school education or more, or rent of $80 per month or more, were considered "middle" class (40% of the sample). "Lower" class individuals had less than a high school education and paid less than $80 per month rent (35% of the sample). The police patients tended to come from the "lower" class (65%) while the medical patients more often belonged to the "middle" class (66%), which is significant at the .05 level. However, social class did not differentiate key family members or decision-makers in the police and medical groups. No differences between the two groups were found for marital status, sex, religion, church attendance, or residential mobility. The distribution of admission diagnoses given the patients in the police and medical groups is shown in Table 5. A significantly greater proportion of police patients were diagnosed as schizophrenic (all paranoid type) or as having personality disorders, whereas the medical patients were more often diagnosed as neurotic or depressed. The differences in diagnoses between the two groups parallel the differences in attitudes of the patients toward getting help as will be shown below.
Recognizing and Defining the Problem A striking difference between the police and medical patients is seen in their degree of willingness to define their problem as "mental" or psychiatric. Denial of mental illness is made by 94% of the police pa-
114
Community Mental Health Journal
TABLE I Admission diagnoses of police and medical cases to state hospital Diagnosis
Schizophrenia Personalitydisorder Neurosis Depression Involutional melancholia Total
Police cases % No.
Medical cases % No.
58 24 x2 6 o xoo
26 14 28 23 9 200
xo 4 2 x o x7
9 5 so 8 3 35
p ~ 0.05, chi square, for differencesbetweenpoliceand medicalcases in schizophreniaand personality disorders vs. neurosis and depression and involutionalmelancholia. tients but by only 29% of the medical patients. The relatives of the patients in these two groups did not show this difference. Over 9o% in both groups viewed the problem as "mental." Three indexes of tolerance for deviance were derived from the time elapsing between (~) recognition of the problem and defining it as "mental," (2) recognition of the problem and seeking help from the first community resource, and (3) defining the problem as "mental" and seeking help from the first community resource. No differences emerged between the police and medical cases on these indexes of tolerance for deviance, either for the patients or for their family members. Similarly, there was little or no difference between patients or family members of the two groups on such important variables as causation imputed to the illness, seriousness attributed to the illness, duration or acuteness of the problem, or patient-family member consensus on these variables. These findings contradict the assumption made by Hollingshead and Redlich (~958) that families who call the police for help with a disturbed member are unsophisticated in their perception and definition of the disturbed behavior, and more tolerant of deviance. The key members of the patient's family were asked whether they thought the patient was to blame for his problem or whether he was just a victim of circumstances beyond his control. The resulting moral judgment passed on the police patient was significantly negative, i.e., blameworthy, more often than for the medical patient. The attitude of the patient toward getting help--his readiness for help-as seen by the patient himself and by the key family member dearly differentiates police cases from medical cases. Tables 2 and 3 show that the police patients are significantly more reluctant to see a need for professional help and less willing to go voluntarily to the state mental hospital. There was marked consensus between the patients' stated attitudes in these matters and the attitudes ascribed to them by their key family members.
Robed Liberman
115
TABLE 2 Patients' definition of their illness or problem at the time of hospitalization
Definition
Police cases % No.
"Mental" or psychiatric Denial of "mental" label Total
6 94 2oo
(2) (26) 27
Medical cases % No. 7i 29 ~oo
(25) (2o) 35
p ~ 0.002, chi square, difference between police and medical cases. TABLE 3 Readiness for getting help from formal community resources
Patients' responses Never wanted help and didn't think it was necessary Knew help was necessary but didn't want to go for it Realized need for help and wanted or was persuaded to get help Total
Police cases % No.
Medical cases % No.
79
(12)
22
(4)
22
(2)
9
(3)
27 2oo
(3) 27
80
(28)
zoo
35
p
