According to the police shootings database compiled by The Washington Post, 25 percent of the individuals fatally shot by law enforcement officers in 2016 were mentally ill.
Similarly, the Boston Globe’s extensive “Spotlight” special report into the mental health care system in Massachusetts found that nearly half of the people shot by police in the last 11 years suffered from mental illness.
In a narrative that has become all-too-familiar, many of these deaths were “suicide by cop” events.
Society seems to expect law enforcement to control every situation that arises. So it’s only natural that issues of police performance, technique and training become the primary focus of criticism and commentary following each tragic death of a mentally ill individual.
Recognizing this, law enforcement has worked to find some solutions.
For instance, the International Association of Chiefs of Police (IACP) has prepared a comprehensive guide to best practices for dealing with the mentally ill. Among other steps, the IACP advocates the development of specialized “crisis intervention” teams to respond to these highly pressurized calls for service.
Just last month, a broad alliance of law enforcement groups, including the IACP and the National Association of Police Organizations, collaborated on a set of improved general “de-escalation” techniques and training models that can be particularly helpful when an officer confronts a person in an acute state of mental distress.
While these efforts are constructive, the narrow emphasis on law enforcement’s interactions with the mentally ill distorts the reality that the police are a part of a much larger system. As a result, the officers involved in these tragic encounters often unfairly monopolize public scrutiny.
Much attention is paid to what law enforcement did, but little or none to the many things that are well beyond law enforcement influence.
More holistic inquiries would likely produce a better understanding of the causes and effects of these deadly incidents. Such assessments could provide a more accurate sense of accountability than current public discourse.
They would reveal what those who have studied the mental health system already know: This isn’t simply an issue of protecting mentally ill protagonists from trigger-happy cops.
The root causes of every fatal shooting can’t really be explained by identifying some “human error” on the part of a cop who used the wrong de-escalation technique. De-escalation techniques are important, but they aren’t magical.
Like the nurse who administers a fatal overdose of medication to a patient, or the air traffic controller who provides an incorrect instruction to a pilot, the front-line officer accused of a fatal “human error” has often, as patient safety expert Dr. Lucien Leape puts it, “been set up to fail.”
The challenge here is not only protecting the mentally ill; it is providing for the safety (or, if you prefer “wellness”) for radiating circles of vulnerable individuals, families and communities.
One circle comprises the officers themselves. About 90 percent of the people shot by police in the Boston Globe study were armed. Besides, as David A. Klinger and others have pointed out, cops who are forced to shoot and kill often suffer deep trauma themselves.
The core question that we should be asking after a fatal confrontation is “How did these two people find themselves in this situation in the first place?” It’s an approach that has worked well in some other high-risk fields, and it would lend itself to assessments of tragic law enforcement encounters.
In aviation and medicine, for example, tragedies are seen as “organizational accidents”—complicated events in which many small mistakes (none of them sufficient to cause the disaster independently) have combined with each other and with latent system weaknesses before the horrific outcomes occurred.
This perspective is based upon the reality that finding one mistake by one “bad apple” usually does little very to provide for systemic improvements.
When it comes to accountability for a bad outcome, an organizational appraisal of this kind reveals that responsibility is often shared by many: usually by those who may have made a mistake, or by those who knew about a shortcoming elsewhere in the system, or by those who failed to anticipate the mistake of another.
Such a broad perspective can provide a level of accountability that is not only more comprehensive, but forward-looking as well.
Hospitals mobilize this principle by conducting “Sentinel Event” reviews that aim to identify the multiple slips, missed opportunities and absent capabilities that combined to cause a bad outcome, and which could combine again to set another front-line actor up to fail.
In fact, if a “suicide-by-cop” occurred within 24 hours of a patient’s release from a hospital, the national accrediting body for hospitals, the Joint Commission, requires the facility to conduct such a sentinel event analysis.
The National Institute of Justice has been leading an exploration of the potential for mobilizing a regular practice of sentinel event reviews in criminal justice aimed at a non-blaming effort to more fully understand the cascading causes of errors and near misses.
The President’s Task Force on 21st Century Policing picked up this theme, and recommended that sentinel event reviews be implemented after critical policing incidents.
Perhaps the most significant benefit to applying a broader lens to fatal police shootings is that it would make clear what should be obvious but is usually ignored. When it comes to the safe handling of acutely mentally ill citizens, the hospitals, the general health care structures, and the cop in the dark hallway who had to pull the trigger are all part of the same system.
Since many of the dead are court-involved, sentinel event reviews of fatalities and near-fatalities involving the mentally ill would ask an array of players from within the legal system to develop an account of their actions and insights.
The prosecutors who brought charges instead of seeking commitment, for example, could consider what in their environment made that seem like the best choice. The defender who delivered the catastrophic bad news and who probably had more private time with the victim than any other practitioner, might weigh how better to detect suicidal ideation and what to do when it is identified.
(Ethical requirements for confidentiality of client communications can make this a difficult problem.)
Corrections staff and medical providers could ask whether continuity in treatment or medication was provided before their detainee was released, or why it wasn’t.
This kind of “root cause analysis” was applied in a recent NIJ-funded study by the Vera Institute, and its utility in a broader review of mental health fatalities would likely be significant.
Most importantly, a sentinel event review process could incorporate all of the criminal justice actors who, although they did their best with the facts and tools available to them at the time, could come together and explore whether certain changes are needed to avoid participating in the same kind of negative outcome in the future.
Another important advantage of this approach is that it can be focused locally. That ensures the process is informed by an intimate knowledge of local considerations and constraints, and eliminates practitioners’ reasonable concerns that some group of pundits from outside a given community will render a judgment without knowing the particular environment in which they operate.
Not every town can fund a Crisis Intervention capability; de-escalation techniques don’t answer every situation.
In fact, no lock-step national mandate of tactics and techniques can provide safety in every situation and jurisdiction.
This is a system problem, not a police problem.
It is not realistic to suggest that any single change by one actor can prevent a negative outcome while we continue to sidestep the fact that there is a larger system of actors, all of whom may have contributed to the outcome, but who also deserve the right and ability to collaborate in systemic corrections.
On a national scale, we have neglected to do this. As a consequence, we are failing to focus on safety in the criminal justice system.
Making the sentinel event approach part of our efforts to strengthen police accountability—in particular integrating it into an analysis of system-wide safety weaknesses— can make a difference the next time a a terrified patrol officer with a Taser and a gun confronts a psychotic with a sword.
Until now, we have been looking at such confrontations—and their often tragic consequences—with blinders. That’s a disservice to the officers who police our communities and to the public, which reasonably expects the systems established for public safety to learn from mistakes.
Jim Palmer is the executive director of the Wisconsin Professional Police Association, which represents nearly 10,000 members from almost 300 agencies. James Doyle is a Boston defense lawyer and author, and a frequent contributor to The Crime Report. They welcome readers’ comments.