Why Are Police the Wrong Response to Mental Health Crises? (ep. 122)

October 8, 2020
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Over the last months, we’ve explored different conversations on the subject of policing: abolition, violence and accountability, protest and activism. Today, we’re exploring a topic that has gained more attention in the wake of Daniel Prude’s death in March at the hands of the Rochester Police Department: the startling connection between mental health 911 calls and police brutality. 

Studies show that nearly 50% of police victims are living with a disability, predominantly a mental health disability. In many ways, 911 has become the only option for people looking for mental health crisis intervention. And police often arrive at the scene armed with deadly weapons and a lack of mental health training. The results are devastating. 

But there is hope. There are new alternatives to policing that can provide real care if we invest in them. Joining us on this episode to break down the issue is Gregg Bloche, a professor of law at Georgetown University and a mental health care policy expert, and Ellie Virrueta, an organizer with Youth Justice Coalition. 

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MOLLY KAPLAN
[00:00:01] From the ACLU, this is At Liberty. I’m Molly Kaplan, your host.

Over the last months, we’ve explored different conversations on the subject of policing: abolition, violence and accountability, protest and activism. Today, we’re digging into a topic that has gained more attention in the wake of Daniel Prude’s death in March at the hands of the Rochester Police Department.

We will dig into the startling connection between mental health 9-1-1 calls and police brutality. Studies show that nearly 50% of police victims are living with a disability, predominantly a mental health disability. In many ways, 9-1-1 has become the only option for people looking for mental health crisis intervention. And police often arrive at the scene armed with deadly weapons and a lack of mental health training. The results are devastating.

But there is hope. There are new alternatives to policing that can provide real care if we invest in them. Joining us on this episode to break down the issue is Gregg Bloche, a professor of law at Georgetown University and a mental health care policy expert. Gregg, welcome to the podcast.

GREGG BLOCHE
[00:01:18 Thanks so much, Molly. It's great to be with you on this critically important topic.

MOLLY
[00:01:22] I want to start first by saying four years and then more acutely this summer, of all the uprisings over the deaths of Breonna Taylor, George Floyd and others, there has been this growing consensus that police are not the solution in a mental health crisis. That punishment and force are prescription for tragedy in addressing what is essentially a health issue. But even before getting into that, I wanted to talk about what happens, even before getting into what happens when the police are called, I want to take a step back and set up sort of the broader context of how mental health is treated in the US and how we got there.

And I think one of the most recent examples that says so much about the system is the case of Daniel Prude, who was killed by Rochester police in Rochester, New York. And this case seems particularly worth noting because his brother, Joe Prude, had brought him to the hospital. His brother had noticed some behavioral changes. His sister had actually sent him to his older brother to sort of address some of them. And Joe brought Daniel to the hospital and the hospital released him, Daniel was home within hours. And then subsequently, Daniel ended up running out of the house. He was naked, it was snowing outside. And Joe called the police because he needed to get his brother back. He was afraid for his brother's safety on a cold day, being naked, and also there were train tracks nearby. And, you know, as many of us know now, that call ended up in the police killing his brother.

GREGG
[00:02:52] Imagine how gut wrenching that will be for the rest of the life of that brother.

MOLLY
[00:02:57] I mean, it's unbelievable. And part of the real issue here is that, what options did his brother have?

GREGG
[00:03:04] We began to foreclose his options more than 50 years ago from 1965 to 1975. A great wave of what became known as deinstitutionalization happens in this country. And it was motivated in part by something wonderful, by way of technological advance and possibility. The wonderful thing, it was beginning circa the mid 50s, we saw the advent of antipsychotic drugs that had the capacity to ameliorate, or at least reduce, the worst of psychotic symptoms. That is the delusional ideas and the hallucinations that say somebody with chronic paranoid schizophrenia or other psychotic illness might have. And this made possible the movement of these patients out of confinement. These folks had been for something like one hundred years before, had been confined in mental health facilities that were initially the products of idealism. But pretty quickly by the latter part of the 19th century, had become little more than warehouses.

So suddenly we had the possibility of freeing these people. But here's what happens during the great wave of freeing folks, which is mainly happens from ‘65 to ‘75. Here's what happens: Rather than setting up a comprehensive outpatient program of care for these people, opportunities to, to work, to be in assisted living situations, etc., what we did was we basically dumped them out on the streets. And we did so with little more than, say, the possibility of going to a psychiatrist once a month or once every few weeks for a psychopharmacology, for a visit to tune up their drugs.

[00:04:58] And so the basic clinical infrastructure for care of these folks to enable their success outside the hospital was not provided. And not only that, but we began to cut subsidies for things like places to live. This rises during the Reagan era when we slash funding for a whole bunch of programs that enable people on the margins to have a safe roof over their heads to work. So we saw in the 80s this rise of homelessness, which is not just something that kind of happens in nature, but rather was the product of policy decisions. So in short, during a period of from say the mid 60s, well into the 80s, we are embarking on this policy of dumping massive numbers of folks who are unable to care for themselves out onto the streets. And we do nothing to ameliorate their situation.

One other quick point I have going on for a bit about this, when the institutionalization was sold to state legislatures, it was sold primarily as a budget cutting method. Had we done it right and provided this kind of comprehensive outpatient support and care, then it might have been, it could have been budget neutral. But it was sold as a way to save money. We don't have to keep these warehouses because the hospitals are going in. And it indeed saved money at the cost of great cruelty.

MOLLY
[00:06:25] Which is such an important lesson as we're talking about alternatives to policing and reallocating budget money away from policing. But one other really important point is to me is that this is not addressing a few adults, depending on what numbers you're looking at, somewhere between one in four and one in five American adults lives with a diagnosable mental illness in any given year. And that seems important because this isn't a one off issue. This is something that as a society, we need to address in a formal and holistic way. This can't be like the afterthought, oh, let the police handle it. Which is what it’s become

GREGG
[00:07:05] Absolutely. If anything, in the COVID era, there's a preliminary reason to think those numbers are going up. There are preliminary studies indicating that many more Americans are experiencing moderate to severe depression symptoms were, pre-COVID.

MOLLY
[00:07:19] And there's also a really critical race element in here, which I know you've looked at yourself and there is an immense amount of systemic racism in terms of access to mental health services and what services are available. And I read somewhere that, you know, only one in three black Americans can receive mental health care when they need it. What have you found in this area?

GREGG
[00:07:41] Look, here's what we do in our country: If there's a gender piece in this well. If you're white and female and you're found to be on the street acting oddly or perhaps even acting in a way that might be seen as dangerous to self or others, you're likely to be taken to an emergency room. You're likely to be pulled into the health care system, whether you're taken there by somebody from EMS, emergency medical services, or whether you're taken there by the police.

MOLLY
[00:08:14] So your health issue is treated as a health issue.

GREGG
[00:08:17] Yes. Yes. But take it to the other end of the spectrum of treatment. If you're African-American and you're male, the same kinds of symptoms are much more likely to be treated as a matter for the criminal justice system. You're much more likely to be picked up by cops than by the EMS, and you're much more likely to be taken to jail. And once you're there, it's the old fish gotta swim, birds gotta fly rule. Those systems treat people as those systems are designed to treat people. So you get funneled into the jail system. Maybe there's some minor offense that you've committed that you're charged with, but that still put you in the lock up until you get access to some sort of lawyer. Or maybe there's some not-so-minor offense that you're booked for, or maybe especially if you're, say, psychotic or severely impaired, maybe when they try to take you in, when they try to shove you into the back of a police car, you act up. Maybe you become physically resistant like George Floyd did. And then the thing escalates. Right? Because you can be charged with more serious crimes. You can be treated more violently by the police. And so add to this structural racism, the street racism that we saw in gut wrenching fashion in the George Floyd affair, the knee on the neck. And you have this toxic, combustible mix. So it's important to see both the structural racism piece and the kind of old fashioned bigotry piece, the street racism piece, and how they can combine to create catastrophe.

MOLLY
[00:09:53] And of course, that carries into once you're in the carcel system. All of those same dynamics play out again, where you have a system that has inherent biases, inherent racism. And then when you mix that with somebody who has a mental health issue, you are further punished, as I understand. Like if you l “act out” in quotes because you are still having a mental health crisis that probably is being treated properly. What happens then?

GREGG
[00:10:18] Right and that’s a huge piece of it. Once you’re in that system, once you're in the jail system, there is too often minimal mental health service capacity available. And there is untrained personnel, whether police or prison guards or whomever else, who simply don't conceptualize the behavior they're seeing as a health problem, they rather conceptualize it as bad behavior, as resistance, etc.

MOLLY
[00:10:44] And getting back to the case of Daniel Prude, I want to confirm with you that based on the facts that we have publicly available, it seems like Joe Prude used every available tool to him within the current system. Is that what it looks like to you as well?

GREGG
[00:11:01] From our, you know, glimpse of this case from a distance, it appears that he acted reasonably. I mean, what would you or I do in an emergency situation? We would, without studying up in depth? We'd have limited options. We probably think if there's an immediate crisis that might put our brother at risk of death, we probably call 9-1-1. And then, look, it ends up being 9-1-1’s judgment. Do they think of this as a fire emergency? Not in this case, right. He said he didn't do that. Do they think of it as an EMS issue or do they think of it as a matter for police? If I call 9-1-1 and say I'm having crushing chest pain, right, that's easy, right? Go send out EMS. This gets more complicated and gets into the realm of how are the 9-1-1 operators trained? How much of a burden do we want to put on them? And what sort of capacity can we build so that in these more ambiguous situations, the first responders have a mix of police capacity and first line mental health evaluation and treatment capacity? Because that's where we want to be. Right.

[00:12:14] And yes, we have lots of public rhetoric about these issues, right. We now have a kerfuffle that's been politicized since we’re something like 40 days from an election about what defunding the police means, whatever that all means. If we can get away from the bare knuckle politics of the whole thing, of what we urgently need to be doing is having immediately available mental health capacity, whether that means some kind of training of 9-1-1 personnel to make better first line judgments. Whether that means having police cruisers with an EMS person in them sometimes, or whether that means having a core of EMS people who you send as the first responders to these situations. I don't know that there's one perfect or proven approach, but it's critical that those are the kinds of personnel that we get out there.

MOLLY
[00:13:07] There's a lot of question and discussion around the training of cops, and there are programs in place right now that they try to teach more de-escalation techniques, especially in cases of mental health crisis. But there's been question about whether or not we should even be discussing the training part and whether wholesale we just need to take cops out of the responder role when it comes to mental health issues. Do you agree with that or do you think here can be both at play?

GREGG
[00:13:35] I think the answer is both. I think we ought to go a long way towards taking cops out of the initial equation. When a 9-1-1 operator can make the determination that there's a mental health issue, then there ought to be a first responder who is trained above all else in that. If not someone specifically trained to deal with mental health crises, then it ought to be E.M.S., emergency medical services. And there's not a huge safety issue there because the vast majority of people with severe mental illness actually do not have a promise to violence, do not pose a threat to others. One of the cultural myths out there is that if you have a severe mental illness diagnosis that you are somehow a really dangerous person. The tragedy is that even folks who are not might well be tipped over through stimuli like what I was describing before that generate panic or rage and paranoia.

MOLLY
[00:14:37] On the flip side, also that people with mental health issues can sometimes end up not only not being the perpetrators of violence, but also the victims of violence.

GREGG
[00:14:45] Oh yeah, absolutely. Absolutely. Victims, and then they lack the capability to let people know what's happened to them. And so they're victims without means for pursuing accountability and without means for preventing repeat by the same perpetrators. So that's a spot on, correct. It just underscores the importance of having other personnel respond to these situations.

MOLLY
[00:15:10] Well, let's take a little bit deeper into some of the alternatives that are percolating. I think we've established that the current system is not working. And some have suggested that what we could do instead, and I know that there is one model that is represented by CAHOOTS in Eugene, Oregon, and actually by others that are now replicating the model where there is instead of having the cops arrive, you have a paramedic and a mental health professional arrive. And one of the really interesting things about CAHOOTS is that they said not only have they saved the city millions and millions of dollars each year, but that only a small percentage, a minuscule percentage of the time out of thousands and thousands of times that they've been called, are the police necessary as well. And I'm wondering if you could speak to some of the alternatives that you're seeing, what seems to be working, what isn't working?

GREGG
[00:15:58] There's lots of ways to do this. And here's where the American model of federalism actually gives us a leg up in terms of trying to figure this out. My understanding is that there really haven't been at this point, good empirical studies to compare the different alternatives. Notice another problem here, from an empirical perspective, you would want to have a controlled study, right? You would want to be able to have confidence that you're looking at, well, the same or very similar populations. And then you're trying different approaches, right. But there are all sorts of obstacles to that. There are ethical obstacles to doing that kind of study with real life humans, you know, our tradition of informed consent, etc.. And then there are problems of implementation since we're talking about public resources and decisions made by political leaders who don't want to be cast as using their citizens, whether it's the people in the street or the cops as guinea pigs, etc.. So they're obstacles to studying this.

[00:17:00] Having said that, we can look at, we can start looking at the results as cities and states start embracing these different models in response to the ferment that we've seen in recent months. We're going to have opportunity to go in and perform imperfect studies that still yield meaningful results imperfect studies of these different alternatives. And one model might, I think should involve much better training of the 9-1-1 operators so that they can make smarter determinations about who to send. Another model, having the capacity, having these psychologically trained EMS people available to deploy. Another model of having some of your police vehicles cruising around. You know, we typically have two people in a vehicle. OK, well, let's have one person be a cop and the other person be a mental health oriented EMS person. And they can share the driver. Or maybe you don't even have, maybe you have some cars that aren't even painted up as police cars because the image of the police car with those sirens on top itself has connotations, right? And so there's a whole variety of models. What they all have in common is this idea of moving this mental health assessment capacity forward rather than keeping it back in, at best, psych emergency rooms so that somebody else has to be smart enough to bring the patients to them in order to even engage.

MOLLY
[00:18:35] And another model we’ve been hearing about, we actually interviewed a young organizer working to solve this problem. Her initiative trains community members so they know what to do in a mental health crisis. We’ll share that later in the episode but I’m wondering Gregg, as someone with mental health expertise, do you think community responders are a good option?

GREGG
[00:18:56] I think it's a good thing to try to do. And in the field, there's been talk about addressing the related problem of stigma for decades. There's the challenge of getting folks' attention. And as is we all know we have more competing for our attention than ever before.

MOLLY
[00:19:25] I was just gonna say that in addition, I think it's worth coming back to where we started, which is all of this needs to happen in coordination with addressing the much larger system, right? The system where we are not giving the daily care, I mean, what you addressed was that when we did the very good work of deinstitutionalizing, we took away the sort of daily check-ins that need to happen. And it seems like this needs to happen at the exact same time that we are trying to find alternatives to policing. So there are fewer instances.

GREGG
[00:19:43] Thank you so much, Molly, for coming back to that. This is critical. The kind of mental health care coverage that the Medicaid program offers is paltry. We need coverage that's going to support not just the purchase of the drug or its prescription after a five or 10 minute meeting with a psychiatrist. We need the kind of coverage that's going to support the building of extended relationships between caregivers who engage in psychotherapy with an ear towards what's going on in the person's life.

And we need that to be accompanied by models, there's a whole array of clinical models that have evidence that support them, sheltered workshops, halfway house living situations, etc.. And of course, readily available programs to address substance abuse, which is often kind of the way that seriously mentally ill people living on the streets self treat themselves as a form of self medication. And unless we provide mental health care, we have this idea of mental health parity, right. There are statutes that speak to mental health parity, but we haven't realized yet, take one of the shortcomings of the Affordable Care Act -- and I hesitate even to say this, given that there are those who are seeking to destroy the Affordable Care Act. But one of the shortcomings that needs to be brought up is that plans, particularly, say the silver plans that a lot of people buy, have very high deductibles and copayments and they also have limited channels of mental health providers. And those two things together make it very difficult for people even on silver plans to access mental health care without cost, that is for many working class families or many families living on the edge is prohibitive. And then when you go a notch down in the socioeconomic spectrum to people dependent on the Medicaid program, even with Medicaid expansion, then you basically have a desert in terms of mental health capabilities. And that desert creates a kind of dry, fire-prone environment for these kinds of street crisis, as happened in the case of Mr. Prude, to blow up.

MOLLY
[00:21:53] And it seems like, Gregg, if I were going to take one key takeaway from this conversation, that the whole orientation of how we approach mental health from the point where there is a crisis and then before we even get there, is to approach it with a care mentality rather than, yes. And that is that seems to be the piece that has been missing in all of this.

GREGG
[00:22:15] And huge, I think, where race comes in and we don't want to see it often. We don't want to talk about it. But here's where it comes in: If these folks were, you know, all white and all say middle class, the great majority of them were middle class, then I daresay we would be having a much different response to the people found on the street, amore deeply empathic response. It's rather like an example that lots of people have been pointing to in the last few years. The disconnect between how people who were strung out on crack circa the ‘80s were treated, members of disadvantaged minorities and crack is a profoundly dangerous drug because of its sudden, the fact that it was followed by the Depression, that even psychotic professionals accompanied by withdrawal from it. When the drug stops taking effect. Yes, so we treated that as criminal. Yes. If people were suicidal. I remember this from my residency, from my psychiatry residency. They were brought to ERs and somebody said he was going to jump in front of a train at 168 Street Broadway in Manhattan near where I did my psychiatry residency. That person was brought to an E.R.. But usually these people were treated as issues for the police.

[00:23:36] And then we have the opiate addiction crisis that’s expanded throughout the country. But that appeared to initially show up as an issue for rural and small town white folks and some of the same politicians who were harshest towards folks in the city with darker colored skin were suddenly deeply empathic and talked about providing more care, ight> Including Mr. Trump. And so that's kind of an example, opiates versus crack. It's become almost a cliche to point to that difference. But it is an example. It’s an illustration of the way race comes into play. And I think we're doing the same thing when it comes to a mental health capability versus cops, and billy clubs in the big city

I think if listeners can be aware of how these things are connected together, that this has a more than 50 year history that begins with deinstitutionalization and tracks through a series of policy decisions that are made and formed by who we count fully as people and who we just regard. And that disregard has had no small connection to race. It's also had no small connection to gender, I dare submit that we've been harsher to men than to women in this role. And the role of structural racism in creating these larger conditions of disregard. So that when cops are sent to the scene in the case of Mr. Prude, there's a structure in place that they are participating in. And yes, there are some cops who did some gut wrenching, disturbing and wrong things in the case of Mr. Prude. But they were introduced into that circumstance by larger structures that they didn't engineer, which is not to say I'm calling them victims, but I am saying that they are agents that are both responsible and are behaving in ways that are caused by the larger structure.

MOLLY
[00:25:40] Gregg, thank you so much for joining us today. We so appreciate it.

GREGG
[00:25:43] Thanks so much, Molly. Great to be with you.

MUSIC

MOLLY
[00:25:51] As I mentioned earlier, we had the opportunity to speak with Ellie Virrueta, an organizer with the Youth Justice Coalition. She’s helping to implement an important alternative to police response in her community and beyond. The initiative is called CAT 9-1-1 or Community Action Teams 9-1-1.

ELLIE VIRRUETA
[00:26:09] We’re an autonomous network here in L.A. County in SoCal. And we want to be able to operate in teams as community alternatives to 9-1-1. Not by replacing or replicating law enforcement, but just being able to provide skills so that folks in our community can also feel confident in addressing or being able to mediate in a responsive crisis so that we don't have to rely on law enforcement and potentially put ourselves and other people in harm's way. So within CAT 9-1-1, in one, we provide trainings and skill building workshops in these five different areas, five different tracks. And we identified these tracks as areas that we can intervene and provide trainings and workshops. So we no longer have to continue to rely on law enforcement.

So the first one is peace building, which is conflict resolution that can be between individuals or groups in neighborhoods. The second one is police accountability / cop watch. The third track is domestic violence / sexual violence. The fourth is mental health crisis. And the fifth is first aid and wound care. So we have experts in these different areas that we work with and that are also part of CAT 9-1-1 to be able to provide these workshops and train folks in the community. Our goal is for everybody to feel confident in whenever there's a crisis, for folks to have these skills, to be able to address the situation, support each other without calling law enforcement.

MOLLY
[00:27:44] It seems to be a really rational response to the fact that calling the police in so many situations escalates and leads to violence rather than de-escalate and heals, whatever the issue is.

ELLIE
[00:27:58] We've already had these systems of care and they may look very different. So, for example, like in my neighborhood, like where I live, our neighbors, we don't call law enforcement whenever there's an issue. There's one of my neighbors, she has she has mental health episodes every once in a while all of our neighbors, we know that she sometimes has episodes. Even if she gets, you know, loud or starts like just being loud and having going through an episode like none of us call law enforcement because we know that she's going through an episode. And with her, I personally worry that, like, if somebody doesn't know if other folks end up calling law enforcement, it's gonna end up with her getting hurt and, you know, possibly killed. So that's not what we want to replicate,

MOLLY
[00:28:42] What I'm hearing is that you are taking something that, I think many people would experience where their neighbor checks their mailbox where they're out, keeps an eye on the apartment or the house while they're away, just sort of basic principles that we all follow in a sort of more microcosmic way. What you are doing is sort of taking those principles and applying them on a more formalized scale. So where there's more formal training and more, I guess, community accountability in some ways in sort of waking people up to the idea that that doesn't just have to be about, you know, checking mail or watching the house. It can be a wider community that we include.

ELLIE
[00:29:17] Yeah. And I think that it's in my own experience, I think the part, like the, these models of care, is not what's lacking. I actually I've been reflecting a lot. I think that like in communities of color, it's for me and for other folks that I've checked in with, like building community with folks comes very easy.

MOLLY
[00:29:35] Thank you so much for all the work that you do. It was a pleasure speaking with you.

ELLIE
[00:29:38] Thank you so much. I appreciate it. Thank you for having me.

MOLLY
[00:29:45] And thank you all for listening. We’ve launched an exciting series on voting that I hope you’re all enjoying. Every Tuesday ahead of the presidential election, we are answering a new question about voting rights in 2020. If you want to add your question to the mix, give us a call at 212-549-2558, or email us at podcast@aclu.org, and it could be featured on the air.

Until next week, stay strong.

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