Evidence-based Research, Policy, and Practice

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Victims & Offenders
An International Journal of Evidence-based Research, Policy, and
ISSN: 1556-4886 (Print) 1556-4991 (Online) Journal homepage: https://www.tandfonline.com/loi/uvao20
Exploring Police Response to Mental Health Calls
in a Nonurban Area: A Case Study of Roanoke
County, Virginia
Sue-Ming Yang, Charlotte Gill, L. Caitlin Kanewske & Paige S. Thompson
To cite this article: Sue-Ming Yang, Charlotte Gill, L. Caitlin Kanewske & Paige S.
Thompson (2018) Exploring Police Response to Mental Health Calls in a Nonurban Area:
A Case Study of Roanoke County, Virginia, Victims & Offenders, 13:8, 1132-1152, DOI:
To link to this article: https://doi.org/10.1080/15564886.2018.1512540
Published online: 20 Nov 2018.
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Exploring Police Response to Mental Health Calls in a
Nonurban Area: A Case Study of Roanoke County, Virginia
Sue-Ming Yang , Charlotte Gill , L. Caitlin Kanewske, and Paige S. Thompson
Department of Criminology, Law and Society, George Mason University, Fairfax, Virginia, USA
Due to a lack of community mental health services, police departments
in nonurban/rural communities are often the first and only resource
available for individuals experiencing mental health issues. The authors
use both calls for service data and an officer-completed survey to
examine the challenges officers in a nonurban police department face
when responding to mental health–related calls, such as lengthy call
times and increased likelihood of use of force. Though officers feel they
have a duty to assist individuals with mental health issues, many officers
are not satisfied with departmentally available options and desire better
alternatives for responding to mental health–related calls.
Mental health; Policing/Law
Enforcement; rural areas;
Crisis Intervention Team
The extent and complexity of police calls for service (CFS) involving individuals with
mental health issues (MHIs) present a prominent and enduring challenge for many
institutions across the criminal justice system. Beginning with the deinstitutionalization
of individuals with MHI starting in the 1960s, policies growing from America’s “tough on
crime” mentality have redirected a significant proportion of this population away from
community-based services and towards reinstitutionalization in the criminal justice system (Manderscheid, Atay, & Crider, 2009).
As a result of this deinstitutionalization, police officers and agencies are often the first line of
response for citizens experiencing an MH crisis, making the police a primary channel through
which individuals with MHI enter both the MH and criminal justice systems. This situation is
exacerbated in rural communities where specialized resources for those dealing with MHI are
often severely limited or not easily accessible by populations most in need. Indeed, as noted by
Mohatt, Bradley, Adams, and Morris (2006), the dearth of MH professionals (MHPs) and
facilities in rural communities makes it difficult for citizens to seek out and receive adequate MH
care. In these communities, police often take on the role of a 24-hour service provider for tasks
as varied as paramedic, wildlife control, and plumber when trained professionals are unavailable.
Similarly, police officers in rural communities often stand as the only visible and available
resource for individuals and families experiencing MH crises (Russell, 2016, July).
In this study, we use CFS data and the results of a department-wide survey to explore
officers’ experiences with and the challenges of responding to MH–related calls in
Roanoke County, Virginia. Roanoke County Police Department (RCPD) itself is a large
CONTACT Sue-Ming Yang [email protected] Department of Criminology, Law and Society, Enterprise Hall 304,
4400 University Drive MSN 4F4, Fairfax, VA 22030, USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/uvao.
2018, VOL. 13, NO. 8, 1132–1152
© 2018 Taylor & Francis Group, LLC
police agency, but serves a predominantly rural community. We discuss how this majority-rural context affects the ways in which officers respond to individuals in crisis. We
begin with a review of the limited literature produced to date on rural policing before
moving on to examine the general challenges police face in responding to calls involving
individuals with MHI and how these challenges manifest in a nonurban context.
Policing in rural communities
Much of the evidence base for effective policing practices, whether MH-related or otherwise, has been generated in large urban areas. However, a majority of the population of
the United States is concentrated in suburban and rural locations (Weisheit, Falcone, &
Wells, 2006). Efforts to assess the scope and effectiveness of rural policing are both sparse
and dated. While prior research shows that crime rates in nonurban communities tend
overall to be lower than in urban areas, nonurban communities may face comparatively
higher concentrations of certain types of crime, including drug use and production,
domestic violence, and property crime (Kuhns, Maguire, & Cox, 2007; Weisheit et al.,
2006). Nonurban police departments also differ from urban police departments according
to a number of characteristics (such as the higher ratio in nonurban departments of sworn
officers to civilian staff) and place a stronger emphasis on legitimacy and police-community relations due to their close connection with residents (Lum & Koper, 2013). Because
of the low population density in most nonurban areas, police agencies must spread their
limited resources across a wider geographic area when responding to CFS. Thus, a
professional policing model that emphasizes efficiency and crime fighting is less popular
in more rural areas than a community-oriented policing model that emphasizes partnerships with residents to solve local problems.
As noted previously, the general limited availability of social services in rural areas
(especially those providing 24-hour service) means the police are often the only available
resource to deal with crises (Mohatt et al., 2006; Russell, 2016, July; Weisheit et al.,
2006). Thus, rural police face community expectations to use a broad range of problemsolving approaches to address diverse and complex problems. As such, the idea of
“community policing,” – in which officers collaborate with citizens and utilize local
resources to solve problems – is integral to policing rural areas. Relatedly, while the
physical distance between residents in rural communities is often vast, informal social
controls are generally stronger, and these social bonds are important for crime control
(Weisheit et al., 2006). While, in urban communities, community policing is typically
associated with neighborhood watch, “knock-and-talk,” and other traditional policecommunity engagement approaches (Gill, Weisburd, Telep, Vitter, & Bennett, 2014),
police departments in rural areas place a much stronger focus on service provision. In
the MH context, police are often called upon to identify and connect citizens to
treatment resources (Cordner & Scarborough, 2005; Donnermeyer, DeKeseredy, &
Dragiewicz, 2011). However, research on police responses to MH-related incidents in
nonurban communities is severely lacking.
Policing and mental illness
A substantial proportion of individuals with MHI have contact with the criminal justice
system, whether it be in the form of CFS to the police, or of conviction for a crime (to
which mental illness may or may not be a contributing factor) (Manderscheid et al., 2009).
According to a 2006 BJS analysis, around one in four people suffering from MHI have a
history of police arrest (James & Glaze, 2006; Livingston, 2016). Additionally, some policebased estimates of the prevalence of mental illness among individuals who interact with
the police are even higher. For example, in Wilson-Bates’ (2008) survey of officers in
Vancouver, Canada, officers reported that 49% of all CFS involved people with MHI.
Additionally, incarceration is a common life event for many individuals with MHI, with
Reuland and Margolis (2003) noting that “[T]he Los Angeles County Jail, the Cook
County Jail in Chicago, and Riker’s Island in New York City each hold more people
with mental illness on any given day than any hospital” (p. 35). Overcrowding in
correctional facilities makes it hard to incorporate many MH treatment options for
inmates (Haney, 2006; Huey & McNulty, 2005), a problem further exacerbated in rural
areas where MH services in the community are less easily accessible. In such areas with
little or no available MH resources, jails are often used as temporary holding facilities for
individuals experiencing an MH crisis (Sullivan & Spritzer, 1997). As first responders and
street-level justice practitioners, the police are often called upon to assist individuals in
crisis, whether or not those individuals have committed a crime. Thus, police play a
critical role as both “gatekeepers” to the criminal justice system and as facilitators of MH
treatment. Van Den Brink et al. (2012) found that half of MH calls in an urban district of
the Netherlands involved individuals who were not in contact with any MH services at the
time of the call. The police themselves were responsible for bringing 21% of these
individuals into contact with services after the call was resolved. This study also showed
that whether or not the police contacted the appropriate service provider (such as a crisis
drop-off center or other treatment provider) at the time of the call determined the
likelihood that the individual would sustain their engagement with treatment.
Morabito (2007) further argues that the ways in which police respond to MHI are
influenced by the context of the incident. Specifically, the norms of the community, the
knowledge police possess regarding the individuals in crisis prior to the incident, and
various situational factors of the incident (such as the availability of treatment options and
the time needed to handle the incident) all contribute to the decision-making processes of
the police (Morabito, 2007). It is reasonable to posit that differences between urban and
nonurban environments influence each of these factors, thus leading to differences in
approaches to policing MHI in predominantly suburban and rural areas (Decker, 1979;
Morabito, 2007). For example, Decker (1979) points out that in rural communities,
officers tend to be more closely acquainted with citizens and are therefore less likely to
utilize formal mechanisms when responding to low-level problems. This aligns with the
community policing focus in rural communities discussed previously.
Regardless of whether individuals in crisis end up in jail or engage with treatment,
policing individuals with MHI presents a number of unique challenges. Calls involving
individuals in crisis are often complicated and disproportionately time-intensive, greatly
straining police resources (DeCuir & Lamb, 1996; Pogrebin, 1987; Reuland, 2004). When
access to or police knowledge of alternative options – such as crisis drop-off centers – are
1134 S.-M. YANG ET AL.
limited, officers may resort to more law enforcement-oriented tactics (such as arrest or
temporary detention) to handle calls. In Virginia, police have two legal options to detain
individuals on MH grounds: an Emergency Custody Order (ECO) (Va. Code § 37.2–808)1
or a Temporary Detention Order (TDO) (Va. Code § 37.2–1104).2 However, neither of
these options guarantees that the underlying MHI will be addressed, thus creating a
possible “revolving door” situation in which individuals are detained and released without
any MH support, increasing the likelihood of further calls for police service. Adding
further strain to departments, the amount of time officers are required to remain at the
hospital with an individual during an ECO or TDO has increased substantially in Virginia
due to a change in state law in 2014. Furthermore, if a placement in a treatment facility is
not secured before the ECO or TDO expires, the state must provide a “bed of last resort,”
which could be located anywhere in Virginia; given the existing shortage of psychiatric
beds in the state, this law has greatly increased the time individuals spend in police
custody while a bed is located (Kunkle, 2015). In more nonurban regions, including
parts of Roanoke County, these issues pose significant challenges for the police because
there are fewer hospitals nearby and the police must spread their resources over a large
and often remote geographic area. Thus, even in a larger department like RCPD (in terms
of number of sworn officers), the resource strain created by officers spending 8 hr or more
at the hospital is substantial (see also Compton et al., 2010; Sullivan & Spritzer, 1997).
In addition to the time commitment, policing individuals with MHI is challenging
because these individuals may behave erratically and react violently to police contact. In
turn, this may increase the risk that police will use physical, or even deadly, force in such
encounters (Rossler & Terrill, 2017). This can contribute to a vicious cycle as individuals
with MHI who have repeated contacts with the police may be afraid of officers’ actions or
commands, further escalating situations (Boscarato et al., 2014; Meade, Steiner, & Klahm,
2015). As a result, police may interpret the individuals’ behavior as threatening (Ruiz &
Miller, 2004; Teplin, 2000). Of course, such use-of-force situations are not always misunderstandings; individuals in crisis may pose a real threat to police, bystanders, and/or
themselves. For example, using data collected from police departments in Eugene and
Springfield, Oregon in 1995, Johnson (2011) found that police generally used physical
force less often if they perceived individuals as having MHI, compared with those they
perceived as stable. However, he also found (controlling for other individual and situations factors) that individuals with MHI were significantly more likely than those without
MHI to physically resist, assault police, and possess a weapon (Johnson, 2011). All else
being equal, physical resistance leads to a higher chance of police use of force in MHrelated incidents (Engel & Silver, 2001; Johnson, 2011; Morabito et al., 2012; Novak &
Engel, 2005).
Options for policing individuals in crisis
With the numerous challenges in policing individuals with MHI, a number of strategies
have been developed to assist police officers handling individuals in crisis and to ensure
safe de-escalation in emergency situations. The Crisis Intervention Team (CIT) model
is perhaps the best-known police-based (rather than treatment-based) approach to MHrelated CFS. The goals of CIT training are to increase officer knowledge of different
types of mental illnesses, improve attitudes toward individuals with MHI, develop crisis
intervention and de-escalation skills, and help officers feel more confident in handling
MH-related CFS (Coleman & Cotton, 2010; Compton, Bahora, Watson, & Oliva, 2008;
Compton et al., 2014a; Demir, Broussard, Goulding, & Compton, 2009; Ellis, 2014).
The duration of the training program ranges from 8 hr to 40 hr (Police Executive
Research Forum, 2015).3 Many police departments using a service-oriented approach
implement a specialized CIT-trained officer unit to safely intervene in MH crises
(Compton et al., 2010; Deane, Steadman, Borum, Veysey, & Morrissey, 1999;
Reuland, 2004; Watson, Morabito, Draine, & Ottati, 2008). Drop-off treatment centers
– where officers can take individuals in crisis who do not meet the criteria for arrest or
emergency custody – are also used in conjunction with CIT approaches. These centers
have the dual benefit of providing individuals in crisis access to emergency psychiatric
treatment (and ideally referrals to longer-term services, if needed) and freeing-up police
officer time.
Scholars estimate that over 1,000 CIT programs exist worldwide (Watson & Fulambarker,
2012). However, their effectiveness at changing officer behavior varies. While CIT-trained
officers are more likely to refer individuals with MHI to treatment services (Compton et al.,
2014b), a systematic review of CITs found no effects on arrest or use of force (Taheri, 2014).
Scholars also do not know whether CIT training is considered effective from officers’
perspectives. Furthermore, in rural areas it can be challenging to implement CIT because of
the lack of treatment options (including drop-off centers and emergency departments
equipped to handle MH cases) and transportation challenges (Compton et al., 2010;
Watson & Fulambarker, 2012).
Krameddine and Silverstone (2015) discuss the many issues often encountered when
training officers to handle MH-related calls. In addition to highlighting the extent to which
organizations often provide training to officers without first identifying proper outcome
measures (such as reducing use-of-force incidents and time spent responding to MH-related
calls), the authors also note that a focus on changing the MH-related attitudes of police officers
does not necessarily translate to a change in the behavior of officers. Indeed, there is little
evidence showing that a change in underlying attitudes leads to a change in officer behavior
(Krameddine & Silverstone, 2015). Furthermore, the authors note that police trainings given
on a single occasion likely have limited ability to improve interactions between police and
individuals with MHI in the long-term (Krameddine & Silverstone, 2015).
Furthermore, Krameddine and Silverstone (2015) contend that for trainings to be
beneficial, they must use hands-on scenarios that emphasize verbal and nonverbal communication while also working to increase empathy and develop skills necessary to establish
rapport between officers and citizens. Krameddine, DeMarco, Hassel, and Silverstone (2013)
examined the use of scenario-based and role-playing training to improve police interactions
with individuals with MHI. The goal of this training was to improve officers’ self-awareness
of their behavior and to develop skills beneficial to establishing positive communication and
rapport between officers and those they interact with during MH-related calls. Half of
officers (50%) reported that they strongly agreed this type of training would positively
change their interactions with persons with MHI. Krameddine et al. (2013) compared the
data at baseline and six months following the training, finding a 40% increase in officers’
ability to recognize MHI in police CFS (compared with their ability pre-training). The
results also revealed decreases in time spent, weapon use, and use of physical force during
MH-related calls (Krameddine et al., 2013).
1136 S.-M. YANG ET AL.
“Co-responder” models, in which police and MH service providers partner or even ride
together to deal with crisis calls, have also emerged as an innovative approach to addressing MH-related calls. Kisely et al. (2010) examined the impact of an integrated mobile
crisis team in Nova Scotia, Canada, in which police, MH service providers, and emergency
health services formed a partnership to address calls. The mobile crisis service involved a
24-hr crisis hotline run by MHPs and police. For MH crisis visits, a plain-clothes officer
and an MH clinician partnered to address severe and/or acute calls. Front line police
officers were given information on how and when to access the services provided by the
integrated mobile crisis team. Kisely et al. (2010) found the approach resulted in increased
use of services by individuals experiencing an MH crisis and their families, improved
engagement with outpatient MH services, and decreased police time spent on calls relative
to a control group (for similar findings, see also Helfgott, Hickman, & Labossiere, 2016;
Lamanna et al., 2017). These models—particularly those which also integrate psychiatric
helpline and triage services with MHP intervention (rather than diversion programs)—
may offer a useful alternative in rural areas (Compton et al., 2010; Sullivan & Spritzer,
1997). In general, jurisdictions with different population density and spatial landscapes are
suited for different MH response options (Steadman, Deane, Borum, & Morrissey, 2000).
Policing mental illness and officer job satisfaction
The unpredictable nature of encounters with individuals with MHI, and the challenges of
responding effectively, also lead to negative emotional consequences for police officers.
Ruiz and Miller (2004), in a cross-sectional survey of Pennsylvania police officers, found
that around half (49%) of respondents felt “uneasy,” “worried,” or “threatened” when
responding to calls involving an individual experiencing an MH crisis. Almost half (45%)
of officers indicated that they did not feel qualified to handle calls involving individuals
with MHI (Ruiz & Miller, 2004). Importantly, the threat of violence and pressure to deal
with calls in a timely manner can be emotionally and physically taxing for officers, thus
increasing both the risk of officer burnout (Vuorensyrjä & Mälkiä, 2011) and the likelihood that officers would use force under these conditions (Maslach & Jackson, 1981;
Rossler & Terrill, 2017).
Most police officers do not set out with the intent to arrest or use force against
individuals in crisis; rather, they know that criminalizing these individuals only serves
to block access to appropriate services and prevent them from seeking the best possible
outcome for themselves and their families (Engel & Silver, 2001; Kisely et al., 2010).
However, officers operating under these conditions may become frustrated and emotionally depleted when resources are limited or unavailable (Maslach & Jackson, 1981).
Officers who feel they have “maxed out” their psychological capacity and resources for
helping others may become unhappy with their job performance in specific situations and
dissatisfied with their overall accomplishments on the job. These problems can affect
officers at all levels of the police hierarchy (Davey, Obst, & Sheehan, 2001; Zhao, He, &
Lovrich, 2002), and have significant negative implications for officer well-being. Again,
little is known about how the rural environment interacts with officer well-being, but
given the close connection between rural officers and the community (Decker, 1979), it is
likely that these issues are significantly stressful when officers are struggling to provide
appropriate assistance. In community policing research more generally, increased
workload and responsibility coupled with ambiguity at work negatively impact overall job
satisfaction and are sources of stress for police officers (Lord, 1996; Lurigio & Skogan,
1994). It is possible that community- and service-oriented officers in nonurban agencies
may experience similar effects when they feel limited in their ability to help. On the other
hand, community policing is also associated with higher job satisfaction when it allows
officers greater autonomy, creativity in their work, and opportunities to expand their
skills, and when proper organizational supports are in place (Johnson, 2012; Pelfrey, 2007;
Rosenbaum, Yeh, & Wilkinson, 1994; Skolnick & Bayley, 1988; Trojanowicz &
Bucqueroux, 1994). Thus, community-based MH-related policing interventions present
a tradeoff for officers who may experience an increase in overall job satisfaction coupled
with dissatisfaction at the limited options available for positively responding to MHrelated calls.
The present study
As previously discussed, most prior studies examining the policing of individuals with
MHI used data from large urban cities. However, questions remain as to whether these
results can be generalized to nonurban or rural police departments. In the present
study we attempted to fill this void by assessing CFS and survey data from a nonurban
police agency to provide a comprehensive picture of MHI and policing in this setting.
In addition to illustrating the extent of MH problems in this jurisdiction, we also
examined officers’ perceptions of the options available to them when responding to MH
calls, and how job satisfaction is impacted by the perceived ability to help the community solve MH-related problems in the more service-oriented context of a nonurban
Study site
Roanoke County is located in southwest Virginia, approximately 250 miles from
Washington, DC. Its estimated population in 2017 was 93,730, encompassed in an area
of approximately 250 square miles.4 The county’s geographic region is primarily rural and
mountainous, but most residents live in the suburbs of Roanoke, an independent city of
99,837 (2017)5 situated in the center of the county. Roanoke County Police Department
(RCPD) is the primary law enforcement agency for the county, and also has concurrent
jurisdiction in Roanoke city (which also has its own separate police department) and the
neighboring city of Salem and town of Vinton. RCPD has a full capacity of 140 sworn
officers (approximately 1.5 officers per 1,000 citizens). In 2016, of all addresses with more
than two MH-related calls (78 addresses), 61.4% originated from single houses located in
more rural areas.6 Thus, it is reasonable to assume that the extent and quality of MHrelated calls addressed by officers in Roanoke County resembles the extent and quality of
MH-related calls faced by rural police departments, based on the geographic distribution
of such calls in Roanoke County.7
1138 S.-M. YANG ET AL.
Data description
Police data
We obtained CFS data from RCPD to help us understand the types of problems RCPD faces.
RCPD has five call types that are classified as MH related: Emergency Custody Order/
Temporary Detention Order (ECO/TDO), Mental Health (“1096”),8 Mental Health with
Weapon, Suicide Threat, and Suicide Attempt. We refer hereafter to all of these call types
collectively as MH-related calls. Our analysis is based on CFS data from the years 2014–2016.
RCPD also compiles a separate use-of-force database including incidents reported by
individual officers. As the use-of-force report is only available to us after 2014, our use-offorce analysis contains information from 2014 to 2016. RCPD defines use of force as
physical effort on the part of a police employee that is designed to assist the employee in
gaining control of the actions or behaviors of a person or persons.9 The range of responses
may include advice, warning, persuasion, verbal encounters, physical contact, use of lesslethal weapons, and deadly force. Together, the CFS and the use-of-force data provide a
picture of the challenges RCPD officers face in encounters involving individuals with MHI.
Officer survey
We developed a survey to assess RCPD officers’ experiences responding to MH-related
calls and their satisfaction with the current options available for handling these calls. The
survey was administered in July 2016 to all patrol and command staff in the agency.
Officers completed the survey on paper during daily roll call.
Survey questions were quantitative and organized around themes such as officers’
available options for responding to MH-related calls, the time and location from which
MH-related calls most often originated, and officers’ attitudes towards citizens experiencing MH crises. Demographic information included division assignment, tenure with the
police department, and departmental rank. However, for confidentiality reasons we did
not collect data on respondents’ age, race, or gender. RCPD officers are relatively homogeneous, so specific demographic questions may potentially identify individual officers.
Sample description. In total, the research team collected 73 completed surveys. However,
data from only 71 of these surveys are included in the present analysis; two responses were
removed due to those officers being assigned to special operations positions within the
department. These responses were excluded because special operations officers are unlikely to have had much recent or consistent contact with individuals experiencing MH
crises. The remaining 71 responses are from officers in the uniform division.10 The
findings from the survey provide information on officers’ perceptions responding to
individuals with MHI in their community, as well as the departmental context in which
decisions are made regarding MH-related calls. As noted previously, the survey collected
demographic information pertaining to officers’ rank and tenure. There are six different
ranks for RCPD uniformed officers: Police Officer, Police Officer II, Police Officer III,
Police Officer IV, Sergeant, and Commander. The differences between each of the ranks
include a combination of law enforcement experience and education. In order to advance
to positions higher than Police Officer (an entry-level rank), officers must go through
promotional procedures where eligibility is determined according to years of experience,
education level, and having been rated as at least “competent” in annual performance
evaluations. In addition, to demonstrate the skills required for the higher-ranking positions of Police Officer II–IV and Sergeant, officers must take a written exam. Among
officers who responded to our survey, 38.6% held a rank of Police Officer, 35.7% held a
rank of Police Officer II, 10% held a rank of Police Officer III, 1.4% held a rank of Police
Officer IV, 10% held a rank of Sergeant, and 4.3% held a rank of Commander.11 The
officer survey included four categories for officer tenure with the following distributions:
less than one year (11.3%), more than one year but less than five years (40.8%), more than
five years but less than 10 years (19.7%), and more than 10 years (28.2%). The majority of
the officers who responded to our survey had worked in the department for more than one
year, but less than 10 years. RCPD officers participate in Crisis Intervention Team (CIT)
training, which uses a scenario-based curriculum that teaches officers to recognize the
signs of MH crisis in individuals, and to use appropriate techniques to deescalate the
situation and assess the needs of the individual. Among our respondents, 83.1% had
received any CIT training, and among that group 76.1% received the full 40-hour training.
Analysis of MH-related CFS
The RCPD received a total of 39,549 CFS in 2014. 546 were MH-related, accounting for
1.4% of all CFS. The total number of MH-related calls increased from 546 to 558 incidents
between 2014 and 2016, primarily driven by an increase in ECO/TDO calls. These calls
increased from 286 in 2014 to 300 in 2016 (Table 1).
While MH-related calls account for just a fraction of total calls, Table 1 shows the extent to
which they disproportionately consume police resources. The time spent on MH-related calls
increased substantially, from about 3 hr in 2014 to almost 4 hr in 2016. This increase was
particularly pronounced in cases that required police to seek an ECO or TDO, which occurs
Table 1. Average total time spent on call type category by year.
Time, hh:mm:ss (Number of calls)
2014 2015 2016
Mental health-related 2:50:54
ECO/TDO 4:26:58
Mental Health Call (1096) 0:25:07
Suicide Threat 1:14:18
Suicide Attempt 3:30:02
Domestic-related 1:28:18
Property Crime 0:36:13
Violent Crime 1:34:26
Disorder 0:31:00
Drug and alcohol-related 0:54:53
1140 S.-M. YANG ET AL.
when officers deem the individual unable to care for themselves or to be a possible danger to
themselves or others. The time spent on these calls increased by 38.2% between 2014 and 2016,
perhaps reflecting the 2014 change in the law described previously. It is also noteworthy that
ECO/TDO calls were the most common type of MH-related calls, accounting for 53.5% of these
calls between 2014 and 2016.
To gain a better understanding of how MH-related calls compare to other CFS, we
compared five main categories of non–MH-related call types to MH-related calls in
Table 1. During 2016, domestic-related calls (1 hour, 29 min, and 21 s; 1,278 incidents),
property crime (36 min and 18 s; 7,243 incidents), violent crime (2 hr, 7 min, and 3 s; 682
incidents), calls pertaining to disorder (31 min and 55 s; 7,597 incidents) and drug- and
alcohol-related incidents (58 min and 22 s; 732 incidents) all took less average total time
per incident than MH-related calls (3 hr, 52 min, and 45 s; 558 incidents) did. This, once
again, highlights the disproportionate amount of RCPD time and resources consumed by
MH-related CFS.
Officers’ encounters with individuals with MHI
Turning to the data from the officer survey, we first examined officers’ perceptions of how
frequently they encountered individuals with MHI. More than 80% of officers reported that
they encounter individuals with MHI at least once a week (Table 2). This frequency seems
high when compared with numbers reported in objective CFS data (see Table 1 previously).
Though we cannot directly compare CFS data to officer survey results, perhaps the high rate
reported by officers indicates the extent to which resource-draining and potentially traumatic MH-related CFS cause officers to overestimate their prevalence. We also explored the
relationship between officer rank and frequency of encounter with individuals with MHI
(Table 2).12 The majority of the respondents who reported daily encounters with individuals
with MHI have a rank of Police Officer or Police Officer II. Supervisors (Sergeants and
Commanders) reported less frequent (though still substantial) encounters than officers of a
lower rank.13 These results suggest that officer perceptions are highly related to their daily
patrol assignments, and that junior officers tend to be more overwhelmed in interactions
with individuals with MHI than more senior officers. Conversely, this mismatch between
our survey data and the CFS data may indicate that officers often encounter individuals with
Table 2. Frequency of encounters with individuals with mental health issues by rank.
Police Officer
Police Officer
Police Officer
Sergeant Commander Frequency
Everyday 3 7 1 0 0 0 11 (15.7%)
Several times
a week
12 11 4 0 3 1 31 (44.3%)
Once a week 6 4 1 0 3 1 15 (21.4%)
Several times
a month
4 1 1 1 01 8 (11.4%)
Once a month 2 0 0 0 0 0 2 (2.9%)
Once every
few months
0 1 0 0 10 2 (2.9%)
Rarely/never 0 1 0 0 0 0 1 (1.4%)
Total 27 25 7 1 7 3 70 (100%)
MHI during non–MH-coded calls, thus highlighting the degree to which officers must be
prepared to interact with those with an MHI even when responding to other types of calls
(e.g., domestic disturbance, public intoxication, traffic calls).
Use of force in MH-related calls
Another important concern in police responses to individuals with MHI is the risk
that force may be used. Table 3 shows that the number of CFS involving force
increased between 2014 and 2016, although there was a slight decline in the number
of MH-related calls involving force during this time period.14 Nonetheless, Table 3
indicates that, although the overall risk of use of force is relatively low, it is disproportionately higher in MH-related calls compared with calls overall. Across 2014–2016,
64 of 305 total use-of-force incidents (20.9%) involved an MH-related call, even
though MH-related calls comprised just 1.3% of all CFS. Furthermore, from 2014 to
2016, 3.9% of all MH-related calls involved police use of force, compared with 0.2% of
calls overall.
The findings from the use-of-force data analysis are corroborated by officers’ responses to
the survey. We asked the officers whether they had been afraid or felt unsafe when responding
to MH-related calls. The findings show that 55 of the 71 officers surveyed (77.5%) reported
ever being in fear for their own or their partner’s safety during an encounter with someone
with MHI. To some extent, the feeling appears to be mutual given that 85.9% of officers
reported responding to calls in which the individual with MHI appeared to be afraid of
officers. Furthermore, 87.3% of officers said they had ever used force during an encounter with
an individual with MHI. While we do not know whether the use of force is the consequence or
cause of officer fear, the high likelihood of officers using force while responding to MH-related
calls concurs with the aforementioned finding that officers frequently respond to calls that
require an ECO or TDO (situations that commonly require officers to forcibly restrain
individuals) when dealing with individuals in MH crisis.
Options available for responding to MH-related calls
Given our finding that MH-related calls consume much more police time than other types
of calls, we were interested to learn how officers typically responded to and resolved these
resource-intensive calls. Our survey asked officers to identify the most common ways in
which they resolve calls involving individuals with MHI. The top four most common
responses involved voluntary transport to a treatment facility (either by the officer or by a
family member) or involuntary treatment via ECO (secured by the officer or a family
Table 3. Use of force analysis for general police calls for service and mental health–related calls.
2014 2015 2016
Total calls for service 39,549 44,243 44,742
Total mental health-related calls per year (% of total calls) 546 (1.4) 553 (1.3) 558 (1.2)
Total calls involving UOF
(% of total calls)
87 (0.2) 103 (0.2) 115 (0.3)
Total mental health-related calls involving UOF (% of mental health calls) 21 (3.9) 25 (4.5) 18 (3.2)
Note: Complaint of pain resulting from handcuff application has been excluded from the use of force analysis; UOF: Use of
1142 S.-M. YANG ET AL.
member; see Figure 1). For instance, 76.1% of officers reported that they often resolved
encounters by accompanying individuals to the hospital for voluntary committal. About
70% of officers reported using ECO directly (officer requested ECO), or indirectly (officer
recommended that family request ECO) when responding to MH-related calls.
Interestingly, fewer than 10% of officers reported that arrest was a common means of
responding to such calls.15
Officers’ perceptions of CIT training
Outside the more restrictive options of ECO, TDO, and arrest, the CIT is one option
officers may utilize when responding to MH-related calls. When asked about their
opinions of the CIT training they received, 76.6% of the participants who had received
the training agreed that it increases the likelihood that officers will refer individuals in
crisis to MH services. The majority (66.7%) of the trained officers also believed that CITtrained officers are better able to identify individuals with MHI. A little over half (58.3%)
of the CIT-trained officers agreed that CIT-trained officers are more effective at deescalating events involving individuals with MHI than non–CIT-trained officers, and
exactly half (50%) of the CIT-trained officers reported that CIT-trained officers are less
likely to arrest people with MHI if they commit minor offenses.
We also asked the officers what type of information is useful to them when responding
to MH-related calls. Almost all (90.1%) of the officers believed that their own prior
experience with the individual is the most helpful type of information, while 78.9% of
officers stated that other officers’ experience with the individual is very helpful. Only about
half of the officers responded that case reports or information from other units is very
helpful in aiding their response to MH-related calls.
0 20 40 60 80
Arrest & Mental Health Court
No Action
Contact Fire/EMS
File Case Report
Clear Call and Add Notes in Call History
Hospital Transport ECO
Refer Family Member to Petition ECO
Transport to Treatment by Family Member
Voluntary Hospital Transport (by PD)
Percent of Officers Reporting That They
Commonly Used This Method
Figure 1. Common responses to mental health–related calls for service.
Note: Common responses were defined by the top four methods that are frequently used by officers
when responding to mental health–related calls.
Officers’ satisfaction with available options
Another focus of our study was to examine the impact of calls involving individuals with MHI
on officers’ perceptions and job satisfaction. Despite the fact that police responses to MHrelated calls are time-consuming and involve a higher risk of use of force, a large majority of
officers still hold very positive attitudes towards those with MHI and believe both that appropriate treatment can help individuals with MHI (87.1%), and that first responders have a duty to
help individuals dealing with MHI access information and resources (88.4%). However, only
50.7% of officers indicated that they were satisfied with the options available to them (at the time
of the survey) for resolving calls that involved individuals experiencing MHI.16
The present study contributes to the understanding of the challenges police face in
responding to individuals with MHI, particularly in nonurban areas. Due in part to
both the deinstitutionalization of individuals with MHI beginning in the 1960s and
“tough on crime” policies that direct this population away from community services
and into contact with the criminal justice system, recent decades have seen an increase
in the number of individuals with MHI who have repeated contact with police officers
(Manderscheid et al., 2009). This issue is especially pronounced in rural police departments where police officers are often the first (and sometimes only) resource for individuals with MHI (and their families) who are experiencing an MH crisis (Russell, 2016,
July). Previous research shows that because MH-related calls are often time intensive
(Reuland, 2004) and more likely to result in police use of force (Rossler & Terrill, 2017),
they disproportionately consume police resources and place great strain on police officers
and departments. Our analysis of CFS data from the primarily suburban-rural Roanoke
County Police Department concurs with this previous research, finding that MH-related
CFS take significantly longer to resolve than other call types (in 2016 MH-related calls
took an average of 94 min, while other call types17 averaged between 25 and 63 min). Our
CFS analysis also found that MH-related calls accounted for a disproportionately higher
share of use-of-force cases than other call types (for 2014–2016, 3.9% of MH-related calls
involved the use of force, while only 0.2% of all other calls involved the use of force, and
20.9% of all use-of-force reports were attached to MH-related calls).
Results from our police survey highlight the challenges officers face in resolving MHrelated calls in a manner that is both timely and satisfactory to all parties. These challenges
may be particularly pronounced in predominantly rural areas such as Roanoke County,
where psychiatric facilities and resources are often highly selective, and space is scarce.
Furthermore, changes to state laws in Virginia that govern procedures for dealing with
people subject to ECO/TDO have added another layer of complexity to the police’s already
difficult task, especially given that ECO/TDO calls comprise the majority of all MH-related
CFS. While the specifics of the law may be unique to Virginia, the substantial amount of
time police spend resolving MH-related calls or supervising temporary custody of people
who pose an immediate danger to themselves or others reflect challenges that police face
around the country. These difficulties are exacerbated by inadequate resources “upstream”
in the MH system, which can lead to a “revolving door” situation in which people with
MHI are released from the hospital with little to no treatment and police are repeatedly
1144 S.-M. YANG ET AL.
called to assist them. The police are typically the first responders in these situations, but
are rarely equipped to deal with the complex needs of the population they serve.
Although MH-related calls to RCPD accounted for a substantial amount of police
time relative to other calls, the actual frequency of these calls was low, accounting for
only 1.3% of all calls to the police during the time period of our study. However, our
survey revealed that a very high proportion of entry-level officers believed that they
encountered individuals with MHI frequently. As discussed previously, it is possible
that the complexity of these calls coupled with the frustration and stress experienced by
the responding officers may make these calls more “memorable” and lead officers to
believe that they occur more frequently than they actually do. The disproportionately
large amount of time officers spend on MH-related calls may also factor into this
perception. However, we were not able to code for other types of incidents in which the
police encounter individuals experiencing MHI; for example, cases in which people
with MHI are the perpetrators or the victims of a crime. As such, it is also possible that
officers are frequently encountering individuals with MHI during calls not included in
our analysis. This speaks to the breadth of encounters in which the police interact with
this population and highlights the need for better tracking of MH-related calls in police
departments, such as an MH “flag” that can be attached to calls in the computer-aided
dispatch (CAD) system regardless of how the call is classified. This type of data
tracking requires substantial thought and planning to avoid labeling or stigmatizing
any individuals with MHI. For instance, should the flag be based on the officer’s
perception of an individual with MHI, or actual information about a diagnosis? How
should this information be recorded and accessible to officers? This decision could lead
to over- or under-counting of the range of circumstances in which someone might be
experiencing an MH crisis. We discuss this issue further in relation to RCPD’s data
systems in the Limitations section.
While the actual number of use-of-force incidents resulting from MH-related calls was low,
MH-related incidents comprise a disproportionately high number of all use-of-force reports.
For 2014–2016, MH-related calls made up 1.3% of all CFS but accounted for 20.9% of use-offorce reports. The survey results indicate that officers have used force disproportionately in an
encounter involving a person with MHI, and also reveal high levels of fear on both the part of
officers and individuals with MHI (as perceived by officers who interacted with these
individuals). It could be that when officers are more fearful during encounters with individuals
with MHI, they are more likely to use force. Furthermore, individuals with MHI may be more
fearful of police, which may result in more resistance to officers’ actions, thus leading officers
to use more extreme measures to resolve the situation (Johnson, 2011). While the survey does
not allow us to assess the possible causal relationships between fear (of both officers and
individuals with MHI) and use of force, we can speculate that the responses are related in a
way that is meaningful to police encounters with individuals with MHI.
As we have discussed, the limited options available to officers when responding to calls, as
well as the high degree of fear and risk of force inherent in some encounters with individuals
with MHI, may result in officers’ dissatisfaction. The “revolving-door” phenomenon creates a
further heavy burden on officers. Although CIT-trained officers felt that the CIT training was
helpful, a substantial minority of the survey respondents (49.3%) remained dissatisfied with
the options available to them for resolving MH-related calls. As mentioned earlier, officers
who serve rural communities are more likely to experience stress and job dissatisfaction when
they cannot provide appropriate assistance (Lord, 1996; Lurigio & Skogan, 1994). Given that a
very high percentage of officers who completed our survey (87%) felt a strong duty to help
individuals with MHI and their families (see also Engel & Silver, 2001; Kisely et al., 2010), it
must be extremely frustrating for officers to be unable to resolve situations in effective ways.
Given prior research on the role of fear and the potential for misunderstanding in MHrelated calls, there may be further opportunities within the context of CIT training or the
development of co-responder models to enhance police understanding of the complex
range of behavior exhibited by individuals with MHI and the circumstances under which
MH-related calls can escalate. Future researchers should address how innovative methods
such as mobile crisis teams and other co-responder models impact police officer satisfaction, as well as effective resolution for the individual in crisis, and attempt to evaluate
these models in rural communities where possible. Based both on prior research
(Krameddine et al., 2013; Krameddine & Silverstone, 2015) and officer feedback gleaned
through our survey, successful CIT training should also incorporate role-playing scenarios
that specifically address situations where officers need to make difficult decisions regarding
use of force when responding to MH-related calls.
As we discussed previously, the challenges of policing individuals with MHI may be
detrimental to officer stress and job satisfaction. However, the more community- and
service-oriented nature of nonurban police departments presents an opportunity for
officers to be creative and use discretion in their responses to individuals with MHI,
especially in lower-level cases that take up police resources but do not escalate into use of
force or ECO/TDO situations. This in turn may improve officers’ satisfaction with
available options and reduce feelings of “helplessness.” Again, exactly what this looks
like in rural or nonurban communities with more limited resources is difficult to predict,
but it could include proactive visits to individuals with MHI (especially frequent callers)
and their families outside of contact during a crisis call, perhaps in collaboration with an
MHP, to understand their needs and explore options for assistance. It may also involve
building relationships with local service providers and other community institutions that
may support people with MHI (e.g., schools, community centers, places of worship) to
develop best practices for mutual support and effective response.
Our study has several limitations. As noted previously, police departments face substantial
challenges in classifying and reporting on the full range of MH-related incidents. In the
past few years, RCPD began requiring officers to add an MH flag to the disposition code
when closing calls in which they suspect the individual is dealing with MHI, and to change
the call type to 1096 if the officer determines that MH is the source of the problem but the
call is not initially reported as such. However, this rule has not been systematically
enforced, and it may also be challenging for officers to consistently change the call type
when a variety of other factors are at play (e.g., if a crime was committed by the person
with the MHI that needs to be documented). As a result, our CFS analysis may underestimate the number of calls with an MH component. As we have discussed, this may
account for the higher perception of incidents involving individuals with MHI reported by
officers who responded to the survey, relative to the recorded number of MH-related calls.
Furthermore, RCPD only started collecting use-of-force data in 2014 (based on officers’
1146 S.-M. YANG ET AL.
self-report). Thus, it is possible that the use-of-force data are not as comprehensive as they
could be, though we are unable to cross-validate with other external data.
Another limitation of our analysis is the small number of surveys. Despite its nonurban
setting, RCPD is a large department in both its geographic size and number of sworn
officers (approximately 140), so our survey only reached about half of the department.
However, our target participants for the survey were those officers who respond to CFS
and have direct experience interacting with individuals with MHI during patrol. By that
standard, RCPD’s Assistant Chief estimates that our survey was completed by more than
80% of relevant personnel. We are therefore confident that the survey results are representative of RCPD officers’ overall experiences responding to MH-related calls and their
satisfaction with available options for resolution. On the other hand, while our results
provide valuable insights into the challenges police face in nonurban areas when encountering individuals with MHI, the results may not be generalizable to other agencies with
different demographic compositions, or to the large number of law enforcement agencies
in the United States with fewer than 10 officers and even more limited resources (Reaves,
2015), many of which are concentrated in rural areas.
Despite its limitations, our study provides insight into the nature of MH-related calls and
the challenges police face in dealing with these calls in the unique context of a police
agency serving a large, predominantly rural community. In many ways, the experiences of
officers in this agency are comparable to those of officers in urban departments, but the
ability to provide adequate resources to individuals with MHI in a timely manner can be
especially challenging. We hope that these findings inspire further research into the
development of effective co-responder models and enhancements to CIT training that
can be adapted for implementation in a diverse range of agencies across the United States,
as well as more studies of the effects (both positive and negative) of this difficult but
important work on police officers themselves.
1. ECOs are issued by magistrates and require any person in the magistrate’s judicial district
who is incapable of volunteering or unwilling to volunteer for treatment to be taken into
custody and transported for an evaluation to assess the need for hospitalization or treatment.
The individual must meet the criteria (a) mental illness and (b) substantial likelihood in the
near future that the person will cause serious harm to self or others or suffer from serious
harm due to lack of capacity to protect himself from harm or to provide for his basic human
rights. A written petition is not legally required but is helpful.
2. TDOs are issued by magistrates and authorize law enforcement to take a person into custody
and transport to a facility designated on the order. Similar to ECOs, TDOs require evidence
that the person suffers from a mental illness; that, as a result of mental illness, the person will,
in the near future, cause serious physical harm to self or others or will suffer serious harm
due to a lack of capacity to protect against harm or to provide for basic human needs; that
hospitalization or treatment is required, and, for an adult, that he or she is unable or
unwilling to consent to treatment.
3. It is important to note that while 40 hr of CIT training might seem substantial for officers’ job
duties, it is far less than the required training for professional crisis counselors. For instance,
in order to become a Licensed Professional Counselor (LPC) in Virginia, candidates must
successfully complete at least two years of graduate-level coursework in addition to 600 hr of
a supervised internship (in which the LPC candidate practices the skills learned and is
exposed to a wide variety of situations, including crisis intervention; Virginia Board of
Counseling, 2017).
4. https://www.census.gov/quickfacts/fact/table/roanokecountyvirginia/PST045217.
5. https://www.census.gov/quickfacts/fact/table/roanokecityvirginia,roanokecountyvirginia/
6. Each address was manually determined as rural by searching the location on Google Maps
and identifying physical attributes of a rural environment, such as swaths of open land and
the absence of additional nearby houses, as indicators of more rural areas of the county.
7. Based on personal communications with the Assistant Chief of the RCPD and a local MH
service provider, the majority of the MH-related calls occurred in the suburban/rural areas of
the county (August 7, 2018).
8. The code 1096 was developed by RCPD to differentiate general MH-related calls from ECO/
TDO, Suicide Threat, or Suicide Attempt calls.
9. Complaint of pain resulting from handcuff application has been excluded from the use-offorce analysis. While officers are required to file a Use of Force Report for these incidents,
they are not included in the department’s Use of Force database.
10. According to the sample schedules given to us by RCPD, we estimate there were 80 separate
uniform officers on shift (including supervisors) across three platoons at the time the survey
was distributed and completed (Platoon A = 26, Platoon B = 31, Platoon C = 23). Thus, based
on this parameter, the response rate is approximately 89%. While the sample schedules used
to approximate this rate showed the number of officers on duty during March–April 2016
(several months before officers completed the survey), our understanding is that officer
schedules do not change significantly over time. Thus, we believe the estimated response
rate—89%—closely approximates the actual response rate.
11. Though 71 total officers responded to the survey, one individual did not answer the question
“What is your rank?” As such, the rank of one responding officer is not known.
12. We appreciate the helpful suggestion of the anonymous reviewer reminding us of the effect of
exposure to MH events on officers’ perceptions.
13. Nine of the 10 supervisors surveyed reported that they encountered individuals with MHI at
least once a week, while one responded that they encountered individuals with MHI once
every few months.
14. We have confirmed with RCPD’s crime analyst that complaint of pain resulting from
handcuff application has been excluded from the use-of-force analysis.
15. The original question asks: “When you encounter individuals with mental health issues, what
is the most common way you resolve the call?” If officers originally ranked an option as 1–4,
their answer was recoded as “COMMON.” If officers originally ranked an option as 5–11,
their answer was recoded as “UNCOMMON.”
16. Officer satisfaction was measured using the question “Are you satisfied with the current
options available to you for resolving calls that involve an individual with mental health
issues (Yes or No)?”
17. Including domestic, property, violent, disorder, and drug- and alcohol-related crimes.
We want to acknowledge Roanoke County Police Department for their wonderful assistance
throughout the research process. We especially want to thank Chief H.B. Hall, Assistant Chief
R.C. Mason, Assistant Chief J.A. Chapman, Cmdr. M.H. Tuck, Cmdr. R.M. Poindexter, Cmdr. S.M.
Short, Brittni Vineyard, Billy R. Fadorick and the officers of the Roanoke County Police Department
for assisting with the data collection and providing feedback on our earlier drafts.
1148 S.-M. YANG ET AL.
Disclosure statement
No potential conflict of interest was reported by the authors.
This research was supported by grant 2015-WY-BX-0007 from the Bureau of Justice Assistance.
Sue-Ming Yang http://orcid.org/0000-0003-0958-8544
Charlotte Gill http://orcid.org/0000-0002-6037-7614
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