This is a highly vulnerable population, often at increased risk of criminal victimization while also impacting public order. These are the people who roam the streets, sleep outside in rain, bitter cold, or sweltering heat.
Crises, or episodes of acute distress, are the norm. They will behave erratically and draw the attention of law enforcement. They are arrested and placed in jails that may or may not have a mental health unit, and end up housed in GenPop (General Population). This is an expensive process that contributes to jail overcrowding, tension between inmates, and increased stress for Cos (Corrections Officers).
There is little in the way of treatment in Jails, and upon release, they return to the streets and an erratic and unstable lifestyle. Appropriate referral after contact with law enforcement is an opportunity to break this cycle.
Current Methods are Not Working:
The greatest public health failure in American history was the Deinstitutionalization movement. This was the idea of shutting down mental institutions and treating the mentally ill in the community. This was deemed possible due to improvements in medication, which were becoming more effective.
Systemic Problems:
Meds are available that can manage the symptoms of both disorders quite well, but they must be taken every day. Some people are so sensitive to the disorder that the meds must be taken at the same time every day, or symptoms can emerge. I have seen people go from rational, calm, and productive to psychotic in 48 hrs. without meds. The newest meds, meaning those developed since 1995, are much more effective and have much more tolerable side effects. But they must be taken every day, indefinitely.
One of the unanticipated problems that derailed deinstitutionalization was that people did not follow through on treatment. Psychiatric meds only work if they are taken, and they must be taken every day. People would be released from the hospital with meds and a follow-up appointment with a psychiatrist. But they spent too many years institutionalized. They could not function in the community, and many had nowhere to go. They would go off their meds, have a psychiatric breakdown, be re-admitted to the hospital, stabilized, released, and the cycle would start over.
Over time, with the closure of institutions and fewer options for treatment, the streets and jails swelled with the severely mentally ill. Crisis intervention by co-responders may be a shift; an interim measure to stabilize an out-of-control situation, by acting as a contact point and a conduit for outpatient treatment.
Defining De-Escalation & Referral for Mental Illness and Addiction:
Someone in a behavioral health crisis is in an extreme emotional state. They may not be responsive to verbal commands, their behavior may be erratic, and they may feel they have nothing to lose. They may be suicidal, inducing police officers to engage them with deadly force, commonly referred to as suicide by cop, or the more formal Provoked Police Shooting.
De-escalation is part of Crisis Intervention. It is the act of contacting someone in a behavioral health crisis, listening to their grievances, offering them alternatives and options, and therefore instilling hope.
A behavioral health crisis can result from:
Chronic Conditions:
- Untreated severe, chronic mental illness, including schizophrenia, bipolar disorder, or PTSD (Post-traumatic Stress Disorder), is expressed as an acute psychotic episode. The person may be paranoid, hearing voices, or seeing things.
- Substance intoxication can look like an acute psychotic episode.
- TBI (Traumatic Brain Injury). TBIs can result in loss of judgment, inhibition, and a lack of consideration of consequences.
Situational/Acute triggers:
- Overwhelming chronic stress. The person may not have a serious mental illness, but a series of events has piled up and left them overwhelmed and desperate.
- A single extreme incident involving major change or loss can leave someone in a state of despair.
The first step is to turn down the emotions that are spooling up before there is violence to self or others. Sometimes just listening can accomplish this. Someone in a crisis state will be in a F3 (Fight/Flight/Freeze) response. Their bodies are prepared for what they perceive as an existential threat, or a threat to their life, whether or not it is objectively real. They may feel very alone and unheard, and do not want to lose control; they want to regain it. Hearing their grievance is the first step to de-escalation.
One of the worst mental places someone can experience is if they believe they are out of options. They feel hopeless and helpless. There are always options, but they may not be recognizable as such. There may not be many options, or good options, but they exist. Short-term, realistic, workable solutions can be presented.
Breaking the Cycle:
The reality in 2026 is that there are not enough places to house people with severe mental illness and/or substance dependence. Most Psychiatric State hospitals were closed. In 2025, for the first time in 70 years, hospitals will be reopened. If this trend continues, more treatment options will be available. There are short-term Crisis stabilization units, where people may stay for up to a week, and short-term hospitalization on the Psychiatric units of general hospitals.
If substance abuse is the primary concern, there are Detox centers, which provide medical monitoring and support for about 72 hours, during the acute withdrawal phase from substances. There are Drug and Alcohol Rehabs, but they are typically limited to a maximum stay of 28 days, which is the insurance industry norm for reimbursement. These programs will typically not accept a mentally ill patient until they are stabilized.
An option following stabilization is a community residence, houses that are staffed 24 hours a day, where eight to 15 mentally ill people live long-term. Higher-functioning individuals may live in apartments independently, with staff visiting daily or weekly, depending on their needs. Some residences specifically address mental illness and substance dependence. If the main concern is alcohol and/or drugs, there are long-term sober houses, where people can stay for one or two years.
Realities to Consider:
- De-escalation is contingent on force as an option. The commanding presence of several confident, fit, and squared-away police officers can make regulating oneself a more desirable decision.
- Not all disturbed people can be de-escalated. Some people are either too far gone or in despair and are intent on suicide by cop. They came to die.
- Officer and public safety are paramount. There will be a point at which no further talking is required, and measured or lethal force is necessary. Crisis Intervention and de-escalation is not about police officers sacrificing themselves or endangering the public.
- The law must be enforced to maintain public order. The message must be sent that there will be accountability and consequences for violating public order and endangering people.
- Placement options after de-escalation are limited. As noted above, this will be the major challenge after a successful de-escalation. This situation is changing with the re-establishment of state psychiatric facilities.
Concluding Thoughts:
For some, life is a struggle, and they experience crises regularly. Their limited resources and coping skills are further eroded with each event. They have severe and persistent mental illness, often coupled with dependence on drugs and alcohol, poverty, and little in the way of social supports. Their view of reality is distorted, and the triggering event that set off the crisis may be an external reality or a product of their own disturbed minds. These are the people most likely to have repeated contact with law enforcement that could escalate to lethal use of force.
