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

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.

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).

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.

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.

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.)

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.

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,

The police officer basically said, “Look, if you don’t come with me [willingly], then I’m gonna have to handcuff you.” So I rode there in the back of the police car, which very much felt like, okay, I’m being treated like a criminal now, for having a mental illness. Which is not anything in my control. (participant 7, White female high school student)

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:

I was just at my physical [examination] before going back to school . . . and they had one of those “How are you doing?” questionnaires. And I filled it out and [the doctor] kind of freaked out and told my mom she had to take me to the ER or she’d call the cops on her. It was like 1 [p.m.], . . . and we hadn’t eaten lunch yet. My mom asked, “Can we go out to lunch?” and she was like, “No, if you don’t take her straight there, I’m calling the cops on you [now].” (participant 46, White female high school student)

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]).

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 sheriff’s officer was—it was just him, and he was kind of a jerk. After he told me not to touch, again, excuse my language, he’s like, “Don’t touch my [expletive] you [expletive] retard.” Then, sitting in the car with that guy for an hour and 15 minutes on the drive . . . he wouldn’t shut up about how much of a piece of [expletive] he thought that people like me were. And criminals, and you know . . . he equated me with criminals. I was numb at that point. I just looked out the window at other people, and I just thought, “Well, this is my life now.” (participant 20, Latino male college student)

I didn’t know what was going on, really, and he was, again, very aggressive. He told me plainly, he’s like, “Don’t mess around with me or I’ll show you who’s boss.” Very aggressive for the situation. It was really scary. (participant 5, multiracial female college student)

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:

It felt like an interrogation. It felt like I’d done something wrong, and they were interrogating me, trying to get me to admit to something . . . to admit to a crime. Which again, mental illness is not in anyone’s control. That’s why it’s so frustrating because it’s like, I haven’t done anything wrong, other than just I have a health problem. (participant 7, White female high school student)

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:

Yes. I feel because I’m a Black Hispanic and I’m a minority that they just maybe took it differently, maybe judged me in that character that . . . because you know if you see that . . . I don’t know if it just goes with the police too . . . just because I look like that, because of my race, that’s why [what] happened [happened]. (participant 18, Black Hispanic female high school student)

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:

They just said, “Oh, we’re just gonna take you to see a psychologist.” I easily agreed because I just thought, “Oh, I’m gonna go for a few hours, maybe just tell them my situation, they’ll make sure I’m okay.” I get in the car, and we started driving for an hour, somewhere really far, and I had no idea where we were going. Then they dropped me off to this hospital, and I still had no idea what was going on. I still had no idea what I was getting into. (participant 19, multiracial female college student)

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:

I was fine, like, “I don’t need to go,” but [the officers] were like, “No, you’re going to go.” I was so scared. I was horrified, just because I wasn’t expecting it. I think if I was . . . Well, I don’t know if anyone can expect it, but if I was given a heads- up about it, I probably wouldn’t be as terrified, but it was just the way they came to the door, and was banging, and like forced me to leave, and then my sister couldn’t come with me. I was just terrified. (participant 17, Black female middle school student)

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:

[The officer] was . . . [actually] friendly. I think he was pretty concerned. He even messaged me a few days after I left the psychiatric facility to make sure that I was okay, and that he was there, like, if I wanted to reach out or anything like that. (participant 42, Latino male college student)

[The female officer] was awesome. She was really great. She was, like, “I don’t want to make you uncomfortable, but I do have to pat you down. I don’t think you have anything on you, but . . . .” She was very, very nice and she actually sat and talked with me for about 30 minutes, and she goes, “I really don’t want to do this, but I fear for your safety and I will take you there personally.” (participant 23, White female college student)

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:

[The male officer] seemed impatient. Then, once he went inside, the other two officers definitely seemed a lot more gentle. I don’t know if it was because they were female. . . . I think because they were a little bit more gentle or whatnot I got more of the impression that if I said something wrong that they would [not] get mad at me in response to what I was saying. I think that was one reason why I wasn’t willing to talk to that guy. It definitely felt more like [the female officers] wanted to listen to what I had to say, as opposed to just demanding information. (participant 6, White female college student)

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:

The person who was giving me a psych eval was like, “I don’t think you should’ve been [put on an involuntary hold], but we can’t undo what’s already been done.” Because it was issued, they can’t unissue it. Everyone who had done a psych eval on me said that I shouldn’t have been [involuntarily hospitalized], but because the officer was upset [and initiated it], I was [hospitalized]. (participant 5, multiracial female college student)

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:

You guys can go, it’s okay. I trust that you as a father are going to take care of him and make sure he gets the help that he needs. You obviously know what he needs and what can be done and that sort of thing. An [involuntary hold] isn’t going to help in this case. (participant 1, White nonbinary college student)

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:

Generally I don’t like police, [and] I think that law enforcement systems are very badly [run]. . . . They are archaic, they need an overhaul, like many programs in this country do. But . . . now I’ve seen officers doing good things and actually working with people [I feel differently]. If the officer that was with me that night ever hears this, I’d like to thank her. (participant 1, White nonbinary college student)

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).

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.

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.