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Gripping a small knife, a man on a street corner shouts incoherently.
A woman with dementia wanders around a shopping mall, decides to live there and refuses to leave.
Anguished by broken relationships and unpaid bills, a woman lies down in the street.
These scenarios encountered by Honolulu police officers last week represent a small sample of the growing number of emergencies in which officers assisting people in crisis choose to consult a police psychologist.
The Honolulu Police Department is planning to overhaul the way it trains officers to respond to people in crisis.
And a new report by a collaboration of police and health care agencies reveals that one-fifth of citizens who come into contact with a police officer consulting with a psychologist go on to become involved in at least two, and as many as 20, additional police encounters.
The report’s conclusion: people with severe mental illness aren’t getting the help they need.
“There aren’t adequate beds, there aren’t adequate treatment programs and then at that point it just becomes a revolving door,” said Michael Christopher, a police psychologist who leads the Honolulu Emergency Psychological Services and Jail Diversion Program. “Often these people go back on the street. We are keeping them out of jail but we’re not helping them get better.”
Police officers frequently address situations involving people who are mentally ill or temporarily emotionally disturbed in which there is no crime or no victim willing to press charges. The Honolulu Emergency Psychological Services and Jail Diversion Program trains police officers to act as a bridge to mental health services for people displaying symptoms that range from auditory hallucinations to severe substance abuse.
The program is a joint effort of HPD, the state health department, city emergency services, the Institute for Human Services and local hospitals. The training, in its 11th year, is provided by Christopher, who contracts with HPD.
Since 2007, on-call psychologists have provided officers with phone consultations in nearly 30,000 incidents involving more than 15,000 people in crisis, according to Christopher’s annual review of the program’s successes and challenges. In most cases, the person in crisis is transported for involuntary psychiatric evaluation or treatment at a hospital, where they can be kept for a maximum of 48 hours.
But for the sickest of the sick, this level of intervention falls short, according to the report.
Although 81 percent of people in crisis receive sufficient help, the remainder do not receive an adequate intervention, as indicated by their repeat encounters with police.
All told, 19 percent of people in crisis account for 80 percent of all calls made by police officers to an on-call psychologist, the report says.
This statistic, Christopher said, demonstrates the necessity for a more robust health care system with enhanced treatment options and availability for people with severe and persistent mental illness.
“We’re kind of the front door to the mental health system,” Christopher said. “But what happens once they get through the door?”
“There are always things you can do to improve,” he noted, “but at this point the officers can’t get any better without the rest of the health system getting better.”
In May, police responded to a 33-year-old man with an arsenal of loaded weapons in a Waikiki hotel room. Officers seized the man’s guns, which he possessed legally, and transported him to a hospital for a mental health evaluation. The man’s psychiatric medication was found on the scene.
About two weeks later, police found the man in another hotel room with a sword, according to Deputy Police Chief John McCarthy.
McCarthy points to this as a dramatic, but not uncommon, example of a systematic failure to provide those who are sickest with adequate help.
In the first half of 2017, more than 200 people who were assisted by a police officer working with a psychologist were taken to the hospital involuntarily two or more times, according to the report.
Each time a mental health intervention falls short, research shows the person becomes sicker and more likely to engage in serious criminal behavior.
“We’re going to get back to the point where they are institutionalized at some point,” McCarthy said. “We almost have no choice because these people cannot function in the so-called free world — it’s just a matter of when and at what cost.”
Although a person who is involuntarily transported to a hospital for a mental health evaluation could remain in the hospital’s care for as long as two days, issues including a shortage of beds sometimes result in a much quicker delivery of services.
The report does not detail the types or duration of mental health services received by those who are transported to a hospital under the program.
Police officers dealing with people in crisis sometimes assist in arranging voluntary mental health interventions. But these are often refused by a person in crisis. A common and difficult feature of serious mental illness is the inability to recognize one’s own symptoms.
HPD is working to put in place new training for officers responding to people with mental illness. It’s set to kick off in 2019.
The department plans to replace the current program with Crisis Intervention Team training, according to McCarthy. The program is different in that its single focus is officer training. It does not utilize an on-call psychologist model.
“The officers are dealing with it every single day,” McCarthy said. “In a survey we conducted they said they’ll take all the training they can get, and if I were in their position I’d like to know how I can better handle those situations. I’m trained to be a law enforcement officer and deal with violence, but how do you deal with someone who is mentally ill and you can’t rationalize with them?”
McCarthy said 20 percent of the police force will receive CIT training during the first two weeks in January, and some of those officers will become certified to train their colleagues. Every police officer will eventually be trained, he said.
HPD is one of four police departments in the nation to receive a grant from the U.S. Bureau of Justice Assistance to fund the CIT training, McCarthy said. The program is endorsed by the International Association of Chiefs of Police, CIT International and the National Alliance on Mental Illness.
McCarthy said the on-call psychologist model can sometimes be cumbersome in that it “adds another layer” to an officer’s response to a person in crisis. The new training, McCarthy said, focuses on providing officers with the ability to practice responding to real-life scenarios, whereas the current officer trainings are more academic.
Police officers currently contact the on-call psychologist in almost 25 percent of calls involving people displaying signs of serious mental illness or severe intoxication, according to the report.
The report notes that the vast majority of calls are made by a minority of police officers, and some officers do not utilize the program at all. This is most likely because there’s a perception that the most vulnerable population isn’t getting adequate help or because officers don’t view the program’s on-call psychologist component as “real police work,” the report concludes.
In addition to providing police officers with on-call psychologists, the current HPD program trains police officers how to respond to people in crisis and to divert as many mentally ill and emotionally disturbed persons from the criminal justice system into the mental health system as possible without compromising public safety.
It also has a post-booking component that staffs advanced-practice registered nurses in the cell block to screen detainees and determine who may need medication management or mental health screening.
A measure of the program’s success is the consistent year-over-year increase in the number of calls police officers make to a psychologist that result in a mental health intervention rather than an arrest, according to the report.
Although 60 percent of everyone arrested by HPD last year suffered from serious mental illness or severe substance abuse, just 2 percent of all people who interface with a police officer working with a psychologist have been arrested since 2007.
But the enduring challenge is that no amount of increased outpatient services alone will be sufficient to address the needs of those who experience the most severe and persistent forms of mental illness. For this population, easier access to adequate inpatient treatment is essential, the report concludes.
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