Investing in Recovery: The Case for Supporting Non-Police Crisis Response

COMMENTARY

My uncle, who has schizophrenia, was shot by police in summer 2000. After decades of living in the streets, jail cells, and hospital beds across the country, he had finally procured housing and was living in an apartment alone. He was also disconnected from any meaningful mental health services, off his psychiatric medication, and spiraling into a paranoid psychotic state. As my uncle was noticeably sick and carrying a knife, his apartment manager called 911 after seeing my uncle staring out of his window, spinning the blade in his hand. Although the apartment manager felt threatened, he also knew that my uncle had schizophrenia and gave this information in his 911 call.

Two policemen responded, and after a few minutes of talking through the doorway, my uncle opened the door, and they muscled their way in. He backed into his kitchen and was pepper-sprayed by one of the officers. Depending on who is asked, he either dropped the knife or threw it in their direction. Either way, as soon as the knife left his hand, the other officer shot him. My aunt, tasked with cleaning up the horrific scene, remembers how the blood on the linoleum floor stood in stark contrast to the spotless apartment that my uncle otherwise kept. Decades later, when recounting the familial pain, it is chilling images like these that most vividly remain.

“I’m not a quitter, Sam,” my uncle reassures me with his smoky voice, not only about surviving being shot, but also regarding his recent hospitalization with COVID-19. With a twisted sense of justice, after recovering from multiple surgeries and a lengthy medical hospitalization, my uncle was ultimately arrested for assault against a police officer and spent the next several years between prison and state forensic psychiatric facilities. Framed as both the victim and the perpetuator of what is ostensibly the crime of having a serious mental illness, he embodies the violent and criminalized fate of our brothers and sisters suffering from these diseases. Although tragic, I have little doubt that had my uncle been black or brown, the police would not have stopped with 1 bullet and the outcome would have been deadlier.

Approximately 25% of fatal police shootings involve someone in a mental health crisis.¹ Police encounters are 16 times more likely to result in someone’s death if the individual has an untreated mental illness.² This risk is highest among Black men, who, even without mental illness, have a 1 in 1000 chance of being killed by police over their lifetime.³ Decades of relying on police as mental health first responders have led to generations of communities suffering unnecessary prison time, injuries, and death.

Motivated to help people with struggles similar to those of my uncle, I am now in my third year of psychiatry residency training in Brooklyn. I regularly hear from families who fear police response to mental health emergencies. Crippled by the horror stories they have heeded or lived, these families wait until their son or daughter’s illness becomes more life-threatening than calling for help. It is an impossible situation, in which the structural violence has not just eroded the trust in our health care system—it has prevented people from getting treatment at all.

This narrative, however, may be changing. Large cities like New York City, Pittsburgh, San Francisco, and others are starting pilot programs where mobile crisis teams comprised of mental health professionals will be dispatched as first responders to behavioral health calls instead of police.² As a result of the American Rescue Plan, the Centers for Medicare and Medicaid Services (CMS) awarded $15 million in planning grants to 20 states and their Medicaid agencies to expand their crisis services, including mobile crisis teams.⁴

A nationwide intervention is also near implementation. This will be a new 3-digit mental health crisis number, 988, and it will become operational by July 2022.⁵ The 988 number should allow mental health emergency calls to initially bypass police response. Thanks in part to advocacy efforts by the American Psychiatric Association (APA), the US House of Representatives passed several appropriation bills to increase funding for these and other mental health initiatives, some at unprecedented levels. However, as the reconciliation process continues, this funding is still in jeopardy.

As passed by the House, these bills would invest, for the first time ever, in creating a $100 million pilot program to support mental health mobile crisis response in lieu of police. It would also double the Federal Mental Health Block Grant for crisis services and expand funding for the Suicide Lifeline by $87 million to assist with the 988 transition.⁶ While these are small amounts compared to the billions of dollars being debated in increased spending for mental health and substance use disorder treatment and research, this funding, if fought to fruition, would indicate that the need for non-police response to mental health crises is being realized and pursued.

For my uncle and my patients, it will take years to create a sense of safety when calling for help. Whether or not we decide to fully invest in these programs will determine if our family members, friends, and patients with mental illness will continue to be criminalized and killed, or if they will have a chance towards recovery. Here lies the great opportunity for all of us: to demand support for these programs and to be aggressive advocates at every step in the process. Our voices matter and are making a difference.

Dr Jackson is a resident in the Department of Psychiatry & Behavioral Services at SUNY Downstate Health Sciences University. Dr Deb is director of public psychiatry education at SUNY Downstate Health Sciences University and medical officer at the US Department of Health and Human Services.

References

1. Rogers MS, McNiel DE, Binder RL. Effectiveness of police crisis intervention training programs. J Am Acad Psychiatry Law. 2019;47(4):414-421.

2. Rafla-Yuan E, Chhabra DK, Mensah MO. Decoupling crisis response from policing—a step toward equitable psychiatric emergency services. N Engl J Med. 2021;384(18):1769-1773.

3. Edwards F, Lee H, Esposito M. Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex. Proc Natl Acad Sci U S A. 2019;116(34):16793-16798.

4. Biden-Harris Administration awards $15 million to 20 states for mobile crisis intervention. News Release. Centers for Medicare & Medicaid Services. September 20, 2021. Accessed November 15, 2021.

5.SAMHSA awards vibrant emotional health the grant to administer 988 dialing code for the National Suicide Prevention Lifeline. Substance Abuse and Mental Health Services Administration. News Release. June 16, 2021. Accessed October 15, 2021.

6. APA statement on House passage of FY22 appropriations bill providing needed increases for mental health and substance use disorder programs. American Psychiatric Association. News Release. July 29, 2021. Accessed October 15, 2021.