“I Didn’t Know What They Wanted From Me”–the Perspective of Individuals with Mental Disorders on Police Interventions

Encounters between individuals with a mental disorder and police forces can be harmful and dangerous for both parties involved. Previous research explored mostly police officers’ subjective experience of these encounters and focused on their recommendations. The present study takes the perspective of individuals with a mental disorder and investigates their subjective experience of dealing with the police. Thirteen semi-structural interviews were conducted with individuals with a history of mental health problems who have had encounters with the police and experienced contact-based anti-stigmatization interventions as consultants. Interviews revolved around the subjective experience of these police encounters. Questionnaires were used to inquire about context factors, individuals’ perceptions of police officers, and their sense of security during these encounters. Furthermore, individuals were asked to rate police officers’ ability to recognize signs and symptoms of ill mental health and give recommendations in regard to adequate communication strategies, interventions, and police training. The results indicate that encounters were experienced predominantly as positive and non-threatening. Participants emphasized the importance of communication strategies with a focus on empathy and respect. Keeping personal space and satisfying basic needs was recommended. Contact-based anti-stigmatization interventions were regarded as an effective approach to reduce stigma. Empathy and respect are perceived as key strategies for police officers when dealing with individuals with a mental disorder. To promote these strategies, trialogical anti-stigmatization interventions and crisis intervention training, including communication skills and face-to-face contact, are promising approaches.


Introduction
Recent research shows that one in 100 police dispatches involves individuals with a mental disorder and 12% of these encounters take place on the pathway to mental health services (Livingston 2016). Furthermore, studies show that the presence of mental illness increases the risk for police violence (Jun et al. 2020) which can result in an increased risk for mortal injuries in individuals with mental disorders (Crissman 2019;Holloway-Beth et al. 2016) and an increased risk for posttraumatic stress disorders for police officers (Darius et al. 2014). There is a large body of research examining how police officers perceive interactions with individuals with mental illness (e.g., Borum et al. 1998;Litzcke 2006;Oxburgh et al. 2016;Ruiz and Miller 2004;Soares and Pinto da Costa 2019;Watson et al. 2004Watson et al. , 2014Wells and Schafer 2006;Wittmann et al. 2020). Wells and Schafer (2006) show that police officers experience these encounters frequently and mostly due to minor issues. Research suggests that police officers tend to identify mental health needs during these interactions but experience the collaboration with the mental health care system as challenging. Furthermore, there is evidence that police officers have low levels of mental health literacy and lack adequate communication skills (Godfredson et al. 2011;Wittmann et al. 2020), which increases the likelihood that they perceive individuals with mental illness as dangerous and unpredictable (Godschalx 1984;Ruiz and Miller 2004).
In contrast, there is a paucity of research investigating police encounters from the perspective of individuals with a history of mental health problems. Overall, research in this field focuses mostly on individuals diagnosed with schizophrenia, bipolar disorder, depression, or personality disorders (Jones and Thomas 2019). Livingston and colleagues (2014b) found that almost 75% of individuals view contact with police rather positively, although the majority had experienced physical restraint during these interactions. In most cases, these encounters occurred because individuals were in a mental health crisis, committed a criminal offence, were victim of a crime, or were in a street stop. A number of studies investigated the influence of experienced procedural justice and coercion, which is associated with less negative pressure and executed coercion in these interactions (Livingston et al. 2014a;Watson et al. 2010). However, little is known about how police officers' conduct is perceived and what kind of behaviors would be recommended. The aim of the present study was therefore to examine the subjective perception of police encounters from the perspective of individuals with mental illness.

Procedure and Participants
Thirteen participants were recruited from a mental health service provider in Hamburg, Germany in May 2020. Most potential participants had experience with trialogical antistigmatization interventions as part of police training. Trialogical interventions describe a process in which mental health service users, their relatives, partners or close friends, and mental health care professionals meet and share ideas in an open setting characterized by equitable communication and mutual respect. In the context of police training, police officers participate in this process in addition to mental health professionals. The intervention involves two to three service users and one relative sharing their own lived experiences with mental health conditions such as schizophrenia or bipolar disorder. Their presentations include personal his-tories about encounters with police officers while in an acute mental health crisis. Participants are encouraged to ask questions and share their own insights, thoughts, and reflections. The aims are to learn from each other, reflect own perceptions and preconceptions, and improve mutual understanding and communication. A detailed description of the trialogical anti-stigmatization intervention in police training can be found in Wittmann et al. (2021). Inclusion criteria were (1) a (self-reported) past or present severe mental illness (schizophrenia, bipolar disorder, schizoaffective disorder, or personality disorder) and (2) past involvement with the police. All participants declared their voluntary participation in the study. Potential participants were screened for inclusion by a mental health professional in person. Eligible individuals were invited for semi-structured interviews in the facilities of a mental health service provider. Interviews lasted between 40 and 60 min and were transcribed verbatim.

Interview
A semi-structured interview was developed in collaboration with two mental health professionals. We chose an explorative approach that includes six categories in order to represent specific aspects of individuals' subjective experience and to facilitate precise recommendations. The categories were chosen to depict the subjective experience of affected individuals in the best possible way. Participants were asked about (1) the circumstances of the police encounter (question: why did you have contact with the police?), (2) their subjective perception of police officers (question: How did you perceive the contact with the police?), (3) their subjective sense of security (question: How did you feel during the encounter with the police in regard to your personal safety?), (4) helpful communication strategies and recommendations for police interventions (questions: How did you perceive your communication with the police? How do you think police could improve the quality of these encounters? What did you experience as helpful in prior interactions with police?), (5) recommendations for police training (questions: Do you think the police are well prepared for police requests involving individuals with a mental disorder? What do you think police recruits should learn?), and (6) rating of police officers' competences in recognizing signs and symptoms (question: Do police officers recognize mental health problems and how do they recognize them?).

Data Analysis
Due to the explorative focus of the study, we used a summarizing technique referring to Mayring (2014) in order to systematically analyze the interviews. Summarizing is an inductive analysis technique which sums up the content to substantial categories by paraphrasing and stepwise reduction. Therefore, we determined the units for analysis, paraphrased them, and used reduction and selection processes to develop a representative system of categories. Two of the authors, one with police background and one with psychological background, extracted the categories. Representative quotations were selected to illustrate the categories. In a comparable study, Livingston and colleagues (2014b) used a similar technique to analyze qualitative data in order to derive general patterns and themes.

Participants
Nine male (69.2%) and four female (30.8%) participants were interviewed (N = 13). Age ranged from 25 to 70 years with an average age of M = 51.33 (SD = 9.96) years. One participant did not disclose his or her age. Self-reported diagnoses included schizophrenia (n = 8), schizoaffective disorder (n = 2), bipolar disorder (n = 1), and anti-social personality disorder (n = 1). Three participants reported another comorbid mental disorder and one participant concealed their diagnosis.

Circumstances of the Police Encounter
All participants had prior encounters with police officers. Seven participants had encounters because they were reported missing, and police escorted them back to a psychiatric hospital. Six participants were initially taken to a psychiatric hospital by the police. Two participants reported experiencing a physical confrontation with a police officer.
"Police told me I had scratched them and had been hysterical. They forced me to the ground." (Participant 1)

Subjective Perception of the Police Officers
Eleven participants perceived the police encounter rather positively and described officers as respectful and directive.
"They were friendly, polite and helpful. They did not make me feel like a second-class citizen. They respected me." (Participant 3) "The police always behaved fine; I was just psychotic. This justified their actions. If someone screams and behaves erratically, they will be forced to the ground." (Participant 6) "Different, it was hard for me to interpret their [the police officers] behaviour as I was very frightened. The kindness [of the police officers] frightened me." (Participant 5) Two individuals reported multiple encounters and experiences with police officers were mixed.
"My experiences with the police were very diverse. Sometimes they seemed very open minded, when it was a female officer. Sometimes they were very harsh, when there were two male officers." (Participant 2) Some participants stated that an encounter with a person suffering from a mental illness can be very challenging.
"When I am psychotic, I am in a different world." (Participant 11).

Subjective Sense of Security
In this section, we examined the participants' subjective sense of security regarding their personal safety. Many participants did not give a detailed answer but reported a general feeling of safety. Some stated a general trust and would rely on the police if they needed them. Other participants reported that they lost trust in the police. Some felt intimidated and others felt fearless.

Recommendations for Helpful Communication Strategies and Interventions
Six participants suggested that it would be helpful if only one police officer at a time spoke with them.
"Therefore, when only one person spoke to me, I was actually able to concentrate on this person. I found that helpful." (Participant 6) Calm requests using de-escalating techniques were perceived as helpful. Participants wished for easy to understand requests in these encounters.
"I did not know what they [the police] wanted from me. We [individuals with a mental disorder] need short sentences in a clear language." (Participant 9) "Calm and friendly request about what is going to happen now." (Participant 1) Two participants felt overwhelmed by a hectic police officer. Participants recommend police officers should take their time when they encounter individuals suffering from mental illness. Participants also wanted police officers to take them seriously. "I felt overwhelmed by the hectic police officers." (Participant 1) "I am not a second-class citizen. I am mentally ill, but I deserve as much respect as every other human being. I definitely can behave challenging but when the police try to stay calm and de-escalate, I am friendly to them." (Participant 8) Some participants wished that police officers had given them more personal space.
"No direct touching and more personal space would have helped." (Participant 1) Another important aspect was that some participants perceived prejudice against them.
"Back in the days, when I was still young, we used to get in trouble a lot. But I changed. When I was stopped in the streets once, and they found out I had behavioral problems in the past, that put me in a box immediately. I realized, once the officers, I guess, were told about my police file or something over the radio, they started perceiving me differently." (Participant 8) Participants recalled that they had wished police officers had asked about their basic needs, such as the need for drinking, orientation, or empathy.
"When I was in custody once for two or three hours and no one was telling me what was happening, I wished someone had given me something to drink. Or just asked how I am, that would have been helpful." (Participant 12) "[The police officers could have] given me a blanket [when I was naked]." (Participant 1)

Recommendations for Police Training
Eleven participants had been invited to a trialogical antistigmatization in-service training of police officers. The majority therefore had professional experiences with the police. All participants perceived trialogical anti-stigmatization interventions as very helpful.
"I want to reduce stigmatization through these interventions. Also, I am learning something new every time. It feels good to be presenting and people listen to me." (Participant 6) The personal exchange and seeing police officers' perspective change increased for many participants their trust in the police force. Three participants recommended that a few days spent in a psychiatric hospital would give police officers even more of a chance to gain new perspectives.

Rating of Police Officers' Competences in the Recognition of Signs and Symptoms of Mental Illness
Most of the participants did not respond to this question very detailed. Some participants reported that police officers might be aware of a neglected appearance, odd behavior, or a strange manner of speaking. However, participants emphasized that in general only mental health professionals are capable of assessing a persons' mental status.
"The police used to often knock on my door, because my neighbor called them. I had been screaming in my flat and had destroyed everything. But when the police arrived, I just acted normal, and I was calm and talked with them. I knew they wouldn't be able to do anything and there would be no need for them to take me with them. That's why I doubt it that you can notice mental disorders just like that." (Participant 7)

Discussion
The aim of the present study was to examine the subjective experience of individuals with mental illness who have had encounters with the police. Overall, the results indicate that individuals perceived these encounters predominantly positive. In line with our results, Livingston and colleagues (2014b) also found that about three quarters of individuals suffering from mental illness were satisfied with police officers' conduct. However, Jones and Thomas (2019) reported that most individuals rated their previous contact with police negatively, and Salerno and Schuller (2019) found that 75% of individuals diagnosed with autism spectrum disorder reported previous police encounters and the majority experienced these as distressing.
In addition, our results support the importance of communication strategies with a focus on empathy and respect. A recent review also emphasized that individuals diagnosed with mental illness have an unmet need for procedural and emotional support (Gulati et al. 2020). This is in line with research emphasizing the role of procedural justice (e.g., fairness, respect, empathy) and a less authoritarian appearance and communication style (de Tribolet-Hardy et al. 2015;Watson et al. 2010). Increased procedural justice is associated with decreased coercion and use of police force (Livingston et al. 2014a;Watson et al. 2010). Livingston and colleagues (2014a) found that police officers' behavior had a strong influence on the degree to which individuals perceived procedural justice and factors, such as consideration of personal space, one police officer leading the conversation, and formulating requests in an adequate manner, played an important role. The results of our study furthermore indicate that individuals had no clear recommendations on how to recognize mental health problems, which raises the question, to which extent police officers must be able to identify symptoms at all. Almost all participants in this study were experienced in trialogical anti-stigmatization intervention. These interventions have been shown to decrease police officers' stereotypes, negative feelings, and social distance towards individuals with mental illness (Wittmann et al. 2021;Wundsam et al. 2007); however, more empirical evidence is necessary to evaluate the effectiveness of the program. Our results indicate that this intervention is also perceived positively by individuals with a history of mental health problems. Based on this, crisis intervention training, which comprises communication training as well as face to face contact, seems to be a promising approach (Watson and Fulambarker 2012). Future research in this field should examine the subjective experience of individuals more comprehensively. Police encounters are a common experience for individuals with a mental disorder (Livingston 2016; Wittmann et al. 2020), and future studies should build on our results. However, some limitations apply. Due to its subjective nature, retrospective self-reported data is prone to be biased, therefore not necessarily representative, and may not be generalizable across populations. However, this approach is justified as this study specifically focused on individuals' personal experiences of police encounters. In conclusion, police encounters were experienced mostly positively by individuals with a mental disorder. Perceived empathy and respect were recommended strategies for police officers when dealing with individuals with mental illness.
Funding Open Access funding enabled and organized by Projekt DEAL.

Declarations
Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent A researcher informed all partcipants about the content and aims of the study. All participants were informed about their anonymity and voluntary participation. All participants had the possibility to ask questions, had time to reconsider their participation and gave their oral consent. No identifying information of any kind was included in this article.
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