Amid the failures of deinstitutionalization — a decades-long push to treat people with mental illness in the community rather than in mental institutions — police officers have increasingly assumed the role of first responders to psychiatric emergencies; law enforcement agencies across the country are grappling with how to manage this responsibility.
One approach has been to provide police with more training, such as in how to recognize signs of mental illness, techniques for crisis de-escalation and ways to connect individuals with mental-health resources. Another approach involves partnering with mental-health professionals such as social workers.
As medical doctors, psychiatrists are highly qualified experts for handling individuals with mental illness; however, it’s rare to see a psychiatrist working in a police department.
What if psychiatrists worked on the front lines with police?
In Albuquerque, Nils Rosenbaum has been doing just that since 2007, conducting what he has called “street-level psychiatry.” Rosenbaum’s roles have included educating police officers about mental-health issues, conducting psychiatric assessments in the field and serving as a liaison between law enforcement and the mental-health system.
“For me, it’s a no-brainer,” Rosenbaum told me. “This is where the illness is. This is where psychiatry should be.”
In a 2017 paper about this partnership, Rosenbaum, Detective Matthew Tinney of the Albuquerque Police Department and Mauricio Tohen, chairman of the department of psychiatry and behavioral sciences at the University of New Mexico, provided some examples of their work together.
For instance, a man with religious delusions who preached from a street corner was well known to local police, cycling in and out of jail and emergency departments, for at various times throwing rocks at people and yelling. As part of the police department, Rosenbaum was called in to evaluate the man, and he worked with local mental-health professionals to help create a plan for care. When the man’s condition worsened months later, Rosenbaum met with him again and helped coordinate an admission to the hospital.
In other situations, Rosenbaum examined individuals who appeared to be mentally ill, and he identified medical conditions such as delirium and thyroid dysfunction that can mimic psychiatric symptoms but require different medical attention.
Tinney says police officers may struggle to deal with these situations because they lack similar medical training. “We were taking people to the hospital and they could get released relatively quickly,” he says. “We were frustrated because we didn’t know what we were doing wrong.”
By contrast, a police psychiatrist can examine people with symptoms of mental illness, determine who warrants medical attention and help get them the care they need, according to Tinney.
In a 2015 report, Sgt. John Gonzales of the Albuquerque Police Department identified numerous benefits of having a psychiatrist on the force, including better education of detectives about mental illness, increased collaboration with health-care providers and more efficient use of hospital resources. Between October 2014 and October 2015, 15 percent of people evaluated by Rosenbaum in the field were brought to a hospital, of whom 89 percent were admitted, though the report did not include data on how these numbers compare to those of other law enforcement personnel in the field.
Employing psychiatrists even part time might seem like an outlandish expense. (Psychiatrists make more than $200,000 per year, on average, vs. about $60,000 for police and sheriff’s patrol officers.) And psychiatrists are in short supply. A 2017 report found that 60 percent of U.S. counties do not have even one. Hospitals and clinics are struggling to recruit psychiatrists, so police departments might also have a difficult time.
There are plenty of issues involved in hiring a police psychiatrist who works on the streets. When someone speaks with a person like Rosenbaum, for example, does that interaction create a patient-doctor relationship, including expectations of patient privacy? How should police psychiatrists access medical records and prescribe medications when they work outside medical institutions?
Social workers and case managers can perform some of the same functions as a police psychiatrist, often at a lower cost. And many police departments assign calls that involve mental illness to crisis intervention teams staffed by select officers who have received mental-health training.
Still, having completed medical school and residency, psychiatrists have a unique set of skills that enable them to recognize psychiatric and medical conditions, to talk fluently about psychiatric treatments with patients and clinicians, and to coordinate treatment with other health-care providers. In some counties, psychiatrists can perform functions, such as placing patients on psychiatric holds and testifying in court, that other providers may be unable to do.
And despite the expenses associated with psychiatrists, sending them into the field with police officers may, in fact, be cost-effective. A 2015 review suggested that police mental-health programs may lead to cost savings by decreasing unnecessary use of jail and hospital resources, among other factors. The implementation of a crisis intervention team in Louisville led to more than $1 million in annual savings for the city, according to an analysis published in the Southern Medical Journal.
Of course, hiring a psychiatrist won’t fix all of the issues that arise when police encounter people who need mental-health care. Yet in Albuquerque, the police department seems to be investing more in this approach to law enforcement. After working part time, Rosenbaum has become a full-time employee and helps lead crisis intervention training for police officers. Psychiatry residents from the University of New Mexico can rotate through the department as part of their education. Since 2015, the police force has also hired more clinicians with master’s degrees to work in the field.
Mental illness has become a major issue for both law enforcement and health care in the United States. Why, then, should police officers and medical providers work apart?
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.