Youths’ and Young Adults’ Experiences of Police Involvement During Initiation of Involuntary Psychiatric Holds and Transport

In recent years, police-involved shootings have evolved into a major public health issue in the United States (1–3). Research has documented markedly disproportionate risks of police-involved death among people of color, particularly Indigenous and Black men and women, Latino men (4), and individuals with mental illness (5, 6). Concerns about the risks and harms of police involvement have led some advocates and researchers to recommend strong limits on, or even abolition of, police involvement in mental health–related wellness checks and crisis intervention (7, 8). Others have sought to strengthen existing police-focused mental health awareness and deescalation programs, such as crisis intervention training (9, 10). Regardless of this attention, research that has focused on the perspectives of individuals who have experienced police involvement in mental health crises has been surprisingly limited. To our knowledge, there are no published qualitative studies of youths’ and young adults’ experiences of police involvement in crises either in or outside the United States.

Involuntary Psychiatric Hold Laws and Police Involvement in Initiation

Although all U.S. states allow involuntary psychiatric holds, exact policies concerning duration, qualifying reasons, and the types of individuals eligible to initiate holds vary considerably (10, 11). A majority of states allow involuntary holds in cases in which individuals (minors or adults) are perceived to constitute a danger to themselves or others because of mental illness. Many states also permit initiation of psychiatric holds under more expansive circumstances, including perceived “inability to meet basic needs” or “grave disability,” and five states allow holds for individuals who have recently attempted suicide, even without ongoing suicidal ideation (11). Currently, 38 states allow police officers to initiate involuntary psychiatric holds, and in two states—Kansas and Wisconsin—police officers are the only individuals permitted to initiate a hold (11).

Prevalence of Police Involvement

In the United States, Florida is among the few states that fund comprehensive public reports on the initiation of involuntary psychiatric holds for both minors and adults (12–14). In fiscal year 2018–2019, 67% of involuntary psychiatric holds for minors were initiated by police officers, as were 57% of holds involving young adults (14–20). A recent systematic review estimated that, internationally, one in 10 individuals have contact with police during initial pathways to care and that one in 100 police dispatches involve interaction with individuals with mental illness; U.S. rates are likely even higher (21).

Framing of Police Encounters and Service User Experiences

In keeping with findings from studies that focus on death or injury in the context of police encounters, such encounters during pathways to mental health care have almost ubiquitously been framed as a negative experience by researchers of pathways to care (15, 22, 23), with particular attention paid to racial-ethnic disparities in the likelihood of such encounters (15, 16). Aside from an a priori assumption that police involvement would ideally be avoided, however, little in the literature empirically documents the direct negative ramifications of officer involvement, and no published studies focus on the perceived impact on youths and young adults.

Although the qualitative literature on the experiences of police interactions among adults with serious mental illness is not extensive, published studies suggest that coercive police practices, including handcuffing, can undermine trust (17, 18), and, therefore, police may be viewed as the least desirable first responders (19). Other studies, however, suggest that police encounters are not universally viewed as negative by service users, particularly when a broader range of police encounters (e.g., police assistance when a service user has been victimized or is seeking help) is considered (20, 24, 25). The degree of perceived procedural justice has also emerged as an important potential influence on the perceived validity of police encounters (26), mirroring findings regarding other programs with coercive elements, such as court-ordered services (27, 28).

Aims of the Study

In light of these gaps in the existing literature, our goal was to better understand youths’ and young adults’ experiences of police involvement in situations in which police officers served as first responders to a psychiatric crisis. Specific aims were to better understand the perceptions and immediate impact of police interactions and youths’ and young adults’ perspectives on the degree of control officers could exert over initiation and transport decision.

Methods

Overview

We conducted in-depth, in-person interviews with 40 youths and young adults (ages 16–27) who had experienced at least one involuntary hospitalization. Interviews primarily focused on individuals’ first experience of involuntary hospitalization but included questions about any subsequent involuntary holds. Our recruitment strategy was diversified and included the posting of recruitment flyers at community colleges, coffee shops frequented by youths, outpatient treatment centers, and other community hubs. Electronic flyers were disseminated via youth Listservs and social media. Interviews were conducted between November 2017 and October 2019.

Procedures

Participants 18 and older provided informed consent, and minors provided assent along with parental consent. All project interviews were conducted in person, audio-recorded, and transcribed verbatim. Protocols were approved by the University of Pittsburgh Institutional Review Board. The interviews were structured to elicit an initial, open-ended narrative of participants’ experiences, followed by detailed follow-up questions regarding context, precipitants, initiation and transport, experiences in inpatient facilities, and short- and long-term impacts. Analysis of the experience of involuntary hospitalization and subsequent impacts on treatment engagement and provider trust are reported in a companion publication (29).

Approach

The project utilized aspects of both grounded theory and thematic analysis (30–32). In line with grounded theory, the team augmented interview protocols as the project progressed, with additional prompts reflecting emergent topics; utilized constant comparison throughout (ongoing evaluation of similarities and differences across interviews, discussion across the research team); and continued with additional waves of interviews until thematic saturation was reached. Initial coding was inductive and iterative; two authors (N.J., B.G.) coded transcripts separately, compared coding schemes, and ultimately developed a final set of formal codes.

Reliability checks were conducted by using Atlas.ti and yielded a Krippendorff’s alpha of 0.88. After transcripts were comprehensively coded, codes were grouped into meaningful thematic clusters (32) designed to elucidate the core research questions of how participants experienced their interactions with officers and the degree of control they attributed to officers in the context of decisions to initiate holds. Multiple analytic tools were used in this process, including code document and code co-occurrence tables.

Stakeholder Involvement

Members of the research team included multiple individuals with personal experience of involuntary hospitalization, interactions with police in the context of crisis, and initiation of hospitalization (as clinicians or family members). The ways in which personal experiences might shape interpretation were a subject of conversation throughout the project.

Results

Demographic Characteristics

Demographic characteristics for the full sample and the subgroup with police involvement are provided in Table 1. Of the 40 participants, 28 (70%) reported police involvement during initiation of a psychiatric hold, and an additional two participants (5%) described themselves as having been “threatened” with police involvement if they failed to comply with a provider-initiated hold. Of the 28 participants who experienced police involvement, six (21%) were handcuffed during police transport. (Table A in the online supplement to this article provides cross-tabulated Ns and percentages for participant race and gender, by type of police involvement.)

Context of Police Involvement

All episodes involving police took place in Florida. Table 2 describes the individuals who initiated police contact and applicable context. As detailed, officers came to be involved in a variety of ways.

Criminalization and Disciplinary Framing of Psychological Distress

A central theme was the perception among participants that police involvement contributed strongly to a sense of “criminalization”—being treated as if they had committed a crime or done something wrong rather than experienced distress or mental health challenges outside their control.

Multiple facets of participant experiences appeared to contribute to this disciplinary (or punitive) framing. For example, many participants described explicit threats made by providers about police involvement or by police officers about forms of escalation. For example, one participant said,

Threats of police involvement were also reported by participants who ultimately managed to avoid police initiation or transport. For example, one young woman described the way her mother was threatened by a provider until she agreed to provide transport for an involuntary hold, which the provider then formally initiated:

The physical or structural realities of police involvement also reinforced a sense of criminalization or punishment for wrongdoing. These conditions included riding in a police vehicle (e.g., “I felt like a criminal kind of in the back of a police car. . . . I don’t know, but just the back is very—the back has these connotations.” [participant 43, White female high school student]); police uniforms, guns, and stature (e.g., “Seeing them, how big and tall and muscular they are with their guns and all that stuff and you kind of cower in fear.” [participant 14, Latino male high school student]); and handcuffing, especially when visible to others (e.g., “[The officers] took me through the emergency room, in front of all these families. I was handcuffed. That was a shameful thing, seeing all these mothers shielding their kids because I’m in handcuffs. It just made me feel worse.” [participant 42, Latino male college student]).

Perceived Aggression and Callousness

Overall, participants with negative experiences described officers they interacted with as “aggressive,” “callous,” using discriminatory language (i.e., “retard,” “piece of [expletive]”), and/or lacking in respect or compassion:

The nature of these interactions often seemed to reinforce participants’ experiences of involuntary hold initiation as punitive, stigmatizing, morally inflected, and “criminalizing” rather than empathetic:

When directly asked about the potential role of racial-ethnic discrimination in their handling by police officers, most participants of color expressly conveyed that they felt that race-ethnicity had not directly influenced their treatment, although these statements were often paired with broadly cynical views of the police (e.g., “[Race-ethnicity] . . . not really. I just don’t really think the cops really treat anybody with respect. They always, to me, always treat you like a criminal first no matter who you are.” [participant 14, Latino male high school student]).

Meanwhile, others felt or at least suspected that race-ethnicity had a role in their treatment:

Poor Communication

Another major emergent theme was poor communication or lack of communication about or involving officers. For example, many participants reported being told that they were being transported for a mental health evaluation, but no further information was provided. In some cases, young people were not even told where they were being transported. In other cases, officers were perceived as mischaracterizing what was actually happening:

Similarly, none of the participants who reported police officers showing up unexpectedly at their home were provided with any context or rationale by the officers:

Minor Theme: Effectively Communicating Empathy and Concern

In contrast with the negative experiences reported by a majority of the subsample, a small number of participants (N=4 of 28) reported overall positive experiences, characterized by perceived warmth, compassion, and genuine concern for their well-being:

Officers described in entirely positive terms were more often women than men but included officers of both sexes.

In other cases, a gendered contrast was explicitly drawn, with a gentler, less aggressive or nonaggressive approach explicitly attributed to officers who were women:

Perceptions of Officer Control Over Decisions to Initiate Holds or Transport Youth

Many participants stated or implied that, from their perspective, after police were called in, little or nothing could be done to prevent the initiation of an involuntary psychiatric hold. In cases in which providers or parents had initiated police contact, it was also often unclear to the youth what the police had already been told and the extent to which they were acting on information that was reported by others or based on their own situational assessment. In several middle and high school settings, participants also reported group assessments, in which they were questioned simultaneously by multiple staff (principal, school counselor, and a school resource or police officer) and, although the officer then provided transportation, it was not clear to the participants who had made the formal decision to initiate a hold.

After an involuntary hold had been initiated (ostensibly by a police officer), participants’ perception was generally that the hold was “irreversible” even if subsequent providers disagreed:

In a marked contrast, however, one of the participants described an instance in which the police officer involved explicitly decided against proceeding with a hold, which third parties had informally initiated or called in the police officer to initiate, after talking with the young person. In this case, a female officer involved began by undertaking an in-depth assessment (generally absent from other participant accounts), allowed the participant to call in a parent, and considered whether an involuntary hospitalization would in fact do more harm than good. After hearing from the youth and parent, the officer was described as actively intervening with her superior officer (who wanted the youth involuntarily hospitalized immediately), and the father and son were told they could leave:

Unlike the many experiences reported that appeared to undermine young people’s faith in the system (e.g., “I’d never seen the police as a bad thing. I always was like, oh, they’re there to protect us . . . [but that incident] was my first insight into, police officers aren’t always good. They can be bad. They can do bad things.” [participant 7, White female high school student]), the skillful handling reporting by participant 1 instead strengthened or restored it:

Discussion

To our knowledge, this study was the first qualitative investigation of youths’ and young adults’ experiences of the involvement of police officers in the context of involuntary psychiatric hold initiation and/or transport. Within our sample, these experiences were predominantly negative and contributed strongly to the perception of the involuntary hold process as criminalizing, disciplinary, and/or punitive, rather than therapeutic. Negative experiences were not universal, however, and a small subset of participants described positive interactions (i.e., those in which officers communicated empathy and concern, willingness to listen to the young person’s story, and, in at least a few cases, willingness to provide active support or intervene in order to prevent an unnecessary hospitalization). Although a majority of participants of color did not believe that racism was a factor, some did; across the sample, the only participants who expressed outright surprise that they had been treated badly by officers were White, whereas participants of color generally seemed to hold low expectations.

Youths’ and young adults’ experiences that associate police involvement with criminalization and shame broadly align with Link and Phelan’s (33) modified labeling theory, which points to shame, secrecy, and withdrawal as responses to and strategies to cope with a discrediting identity. Participants in this study can be understood as experiencing “double stigma,” a term utilized when two simultaneously discrediting experiences occur (i.e., mental illness and police involvement) (34). Data reveal that participants experienced being treated like or feeling like a criminal and reported that being handcuffed was a “shameful” thing. Stigmatizing experiences have been found to lead to limiting social interactions for youths and young adults, among other negative outcomes (35). Although involuntary holds and police involvement can be unavoidable in some circumstances, these data reveal that police involvement is highly nuanced, can lead to long-term impacts, and may be improved if police officers are trained to respectfully engage young people who are experiencing distress.

Implications for Short-Term or Incremental Improvement

Aside from the more fundamental systemic reforms discussed below, participant accounts indicate areas for focused short-term efforts, including training for officers, providers, and school personnel that effectively conveys the potential harm of invoking police involvement and of particular practices, such as handcuffing. Equally important are provider and police officer avoidance of making threats or using language perceived as threatening during initiation and transport; using neutral, nonviolent communication with individuals in crisis; and communicating with transparency. Adaptations of crisis intervention team (CIT) training for youths offer one promising approach (36); as the adult CIT literature suggests, however, the CIT training component alone, without additional infrastructure and policy change, is unlikely to adequately address the risks inherent in police involvement, and structural changes also need to be considered (37–39). Given variable perceptions of the degree of agency or control officers were able to exert over the initiation of holds and the form of transport (i.e., whether they allowed a family member to transport the young person), our data also suggest a potential need for greater clarity and transparency regarding officer decision making in the complex process of initiating a psychiatric hold (Table 2). Ideally, greater efforts would be made to educate the general public, as well as school and campus communities, about applicable laws, rights, and responsibilities related to initiation and transport.

Participant accounts of the social shame associated with handcuffing and police transport, especially when visible to peers or community members, also underscore the value of alternative forms of transport now being used in some jurisdictions (40, 41). In addition, policies requiring or (at a minimum) allowing family or friends to provide transportation may further reduce potential harms linked to police transport (41).

Officers in the Broader Context of Crisis Response and Treatment Systems

Participant narratives explicitly speak to the ways police involvement can harmfully reframe acute psychological distress as a moral or ethical failing on the part of the youth in distress, meriting punitive rather than compassionate responses. However, these responses form only one link in a chain of decisions culminating in involuntary hospitalization. As suggested by our analyses of participant accounts of hospital facilities and their impact, the negative aspects and impact of police involvement were largely consistent with perceptions of hospitalization itself, rather than an outlier (29). Participants frequently described hospitals and police involvement with the same analogies: facilities were frequently described as jails or prisons in which rights (to privacy, freedom of movement) were compromised, and treatment by the range of providers and staff was described as judgmental and dehumanizing. The disconnect between youths’/service users’ perspectives and the way that response systems are currently configured, which is reflected in both direct study findings and the thin academic literature on youth/service user views, also underscores the importance of greater youth and service user involvement and coleadership in systems change and redesign work.

Meanwhile, participants’ accounts clarify that alternatives to hospitalization were largely unavailable or inaccessible; among those who had accessed care both before and after hospitalization, quality was often perceived to be very poor. From a systems perspective, participants’ accounts align with analyses arguing that police officers are often involved in crisis response because of major underlying gaps in health and social care access and/or quality (8, 41–43). Drawing on both the perspectives of youths in our sample and data on poor service quality and barriers to access, we argue that police involvement and the various risks it carries are better framed as a result of an underfunded, underresourced system that consequently overrelies on both acute care and coercive mechanisms than as a result of law enforcement involvement. That is, even if we removed police officers from the equation, major structural and clinical problems would remain.

Limitations and Future Directions

Our sample was composed predominantly of women, and, although a majority of participants were non-White, Black youths were underrepresented. Given documentation of the specific harms of police involvement in Black communities (1–6), additional research focusing on the experiences of a larger group of Black youths should be a priority. Very few of our participants described prior involvement with the criminal justice system, which may have had a substantial impact on their interactions with police. Furthermore, all interviews were conducted in Florida; given variations in policy across states, more work is needed to understand the extent to which the findings reported here might be generalizable to other contexts. Future policy reforms would benefit enormously from research involving large representative samples that can be used to estimate the actual prevalence of negative experiences, state variation, and potential racial inequities.

Conclusions

The Black Lives Matter and Defund the Police movements have helped draw attention to the risks of police involvement in the context of mental health crises and nonviolent domestic disputes (1–6)—risks that have in turn raised difficult questions about social and structural inequalities both within and outside health care systems. The findings reported here contribute to this conversation in centering the perspectives of youths and young adults with mental health challenges and in highlighting the ways in which police involvement may contribute to inappropriately punitive (or criminalizing) responses to youth mental health crises—responses that further stigmatize young people. Rather than construing police as the primary drivers (or culprits), we suggest that our study findings underscore the need for a deeper examination of extant policies and practices and for serious consideration of more fundamental policy change.