Elizabeth Wexler stands at a chalkboard at the Baltimore City Police Training Academy while 50 cadets look on. She draws a large "T" and asks the class to say what comes to mind when they think of mental health.
"Schizophrenia, dementia, aggressive behavior," the cadets shout.
"What was that?" Wexler asks.
"Aggressive behavior!" the cadet repeats.
"Crazy and Aggressive, that is the one I wanted to hear," Wexler says. She turns to the other side of the T.
“Same thing — what comes to mind when I say the word ‘cancer’?" she asks.
"Disease, doctor, diagnosis, money!" the cadets shout.
Wexler stops writing and turns to the class.
“What is the difference between these two?" Wexler asks. The cadets are silent. "We have a lot more compassion. We see cancer as a disease more than we do mental health. If you think about it, there are many more life choices that can lead to this" — she points to the cancer side of the T — "than to this."
Nearly one in five adults experiences mental illness each year, according to the National Alliance on Mental Illness, or NAMI, and there are roughly 87,000 people with mental illness in Baltimore. But police interactions with those people often result in violence.
New training by the Baltimore City Police attempts to change that dynamic, beginning with cadets.
It’s vital that police officers understand the stigma they attach to mental illness when they are out on patrol, "much more than in the past because they meet people with chronic mental health issues that used to be treated in institutions and they aren’t anymore," Wexler says.
The 16-hour course for cadets is supposed to give them a big-picture understanding of mental illnesses. Wexler gauges their attitudes toward and knowledge of mental health conditions through diagnostic tests at the beginning and end of the course.
These exams include questions such as, true or false: All people with mental health illness are on medication.
Another one: The main cause of mental illness is a lack of self-discipline and willpower.
That is also false.
Okay, a harder one: When a licensed mental health professional writes an emergency petition to gain access to a mental health treatment center, it does NOT also require a judge’s signature.
While this course is required at the academy, there is no requirement to pass this test. Still, Wexler says the course’s purpose is to give officers more confidence to recognize the signs of mental illness on the streets.
“The idea of this training is not to turn police officers into clinicians," Wexler says. "The idea is to give them a better sense of how to identify when people need assistance rather than something be construed as a law enforcement situation.”
The Baltimore City Police Department’s failure to de-escalate a situation or call mental health providers for assistance was one of the findings in the investigation the U.S. Justice Department released last year. The investigation also found officers routinely using unreasonable force against individuals with mental health disabilities in clear violation of the Americans with Disabilities Act. That law requires officers to change how they operate as needed to avoid discriminating against people with disabilities, including mental illness.
Since 2004, the department has provided specialized training to cadets, but that standardized training was not provided other officers.
“Generally what standards do is to define what task or activity or written directive or training needs to occur in a particular area," says Louis Dekmar, vice president of the International Association of Chiefs of Police, or IACP, and former chair of the Commission on Accreditation of Law Enforcement Agencies, or CALEA.
When it comes to assisting those affected by mental illness in order to be in compliance with those standards, Dekmar says, police departments are required to provide mental health training to cadets when they first arrive, as well as to experienced officers throughout their tenure.
Prior to the consent decree, the department did not meet those training standards.
Now the department says it provides a mental health component within in-service training. And under the police department’s recent consent decree, it is required to include eight hours of in-service mental health training annually.
Back in the classroom, officers are introduced to two individuals with mental illness from NAMI. They share their personal stories about their mental health conditions and answer questions.
“I could talk for a week as a subject-matter expert," Wexler says, "but if I don’t have a personal story it certainly doesn’t have that level of powerful impact."
Finally, cadets get a 40-minute exercise in understanding auditory hallucinations.
"The voices come and go, and sometimes they get loud and sometimes they get softer, and sometimes they are funny, and sometimes they are distressing," says Wexler.
While audio is playing, cadets take a reading comprehension test and have an interview with a mental health professional. Wexler wants the cadets to see how difficult it is to focus on a task while inundated with voices.
In the field, these auditory hallucinations are the most common type of mental health condition, she says.
Louis Dekmar agrees. He says cases occur frequently and are often unpredictable.
“Dealing with those with mental health illness has been thrust upon the police community, and that’s consequence, in my opinion, of failure of public policy," Dekmar says.
He says that in the 1960s, the nation had more in-patient treatment options for those with mental health conditions. Today, he says, county jails and state penitentiaries act as treatment facilities for dealing with the mentally ill. According to the Bureau of Justice Statistics, nearly a quarter of state and local inmates have a mental health condition.
Given how frequently the criminal justice system and mental illness overlap, Wexler says it’s key that police set aside stigma or preconceived ideas — "not only recognizing when someone is having hallucinations so that might temper their interaction, but also compassion of how difficult it is to concentrate when someone is asking you a question and really pressuring you to answer when the voices interfere."
She says she hopes officers can be that understanding and compassionate in the field.