Abstract
Police and law enforcement providers frequently come in contact with individuals who have psychiatric disorders. Repeated studies suggest that greater understanding of psychiatric conditions by police officers would be beneficial. However, few training approaches have been examined. We present a novel approach to training police officers to interact with those who may have a psychiatric disorder. This approach involved development of a program in which police officers interacted with actors highly trained to present one of six realistic psychiatric scenarios. Confidential feedback was given, both by experienced police officers and by the actors, to improve awareness of the officers' behavior. Qualitative feedback from both officers and actors was used to determine the acceptance of role-play training. A total of 663 police officers were trained, with feedback from 381. Results showed that this approach was well accepted by most police officers, and the use of carefully controlled role play in training for police is strongly recommended. Future analysis will determine whether training improves police behavior with respect to interaction with mentally ill individuals.
Individuals with various psychiatric problems, including addictions, depression, and schizophrenia, have an increased probability of coming into contact with the police. However, it has long been recognized that police officers lack confidence in their interactions with this group,1 which may in part be due to insufficient knowledge about mental illness.2 Most police forces have some training on psychiatric conditions, but the types of training vary widely in nature, design, duration, and timing (whether during police academy instruction or after graduation).3 To date, there has been very little research about the best training approaches.
Research has suggested that interventions can change reported attitudes toward individuals with mental health problems and that training can help police officers feel more informed and confident in how to support individuals in mental distress.4 However, the best methods for educating the police force remain uncertain. Although training seminars have increased knowledge about specific psychiatric conditions, they may not change attitudes5 or behavior, just as specific training on de-escalation techniques may not decrease the number or severity of physical interactions between individuals with mental illness and health care providers.6
One method that may help is to improve empathy, although how best to achieve such improvement remains uncertain.7 Training in crisis intervention for police officers has also been studied and may increase the ability to recognize and respond to individuals in crisis, reduce the stigma of those with mental illness, and increase empathy for these individuals.8 There has also been research suggesting that improving police officer skills in dealing with individuals who may have psychiatric conditions results in fewer arrests.9 In addition, more reliable methods have been developed to measure attitudes and intended behavior of police officers toward individuals with psychiatric conditions.10 These methods will help future studies in this area.
One widely used method of improving interactions between police officers and those with mental illness has been the Crisis Intervention Team approach.11 The most widely used variant is a voluntary 40-hour program that “provides law enforcement based crisis intervention training for helping those individuals with mental illness” (Ref. 12, paragraph 3). However, although this approach is widely used and the results of some studies have suggested that it may reduce hospitalization rates,13 a review examining its effectiveness suggested relatively few benefits,14 and others have been even more critical of the approach.15
Other approaches include an attempt to address specifically the stigma of mental illness and to challenge established views held by police officers that link psychiatric disorders to violence. This approach involved two separate two-hour workshops combining small group approaches with didactic presentations, and the results showed some benefit, although not in the linkage between psychiatric disorders and violence.4 Another approach, which occurred following a review by the California State Legislature, led to further analysis by law enforcement professionals who suggested that an 8-hour program could be very useful if well designed such that it is action oriented and hands-on,16 although specific details of the possible benefits of this approach do not appear to have been published to date.
In terms of the best approach to training police officers, techniques used in other adult learning environments may also be appropriate. In medical training, it is now well documented that the use of role play with simulated patients is preferable over classroom learning.17 As well, “students appear to enjoy and learn through their active participation … and appear more engaged” (Ref. 18, pp 269–270). The use of role play in police training, nonetheless, has rarely been studied, and the only study to date suggested that role playing should be secondary to small group discussions and videos,19 although it did not clarify the nature of the role playing involved or whether the part of individuals with psychiatric conditions was played by other police officers.
The evidence gathered to date show that it is widely accepted that training police officers to interact better with individuals who may have psychiatric disorders is important. Nonetheless, there are no currently accepted models that appear to have reproducibly positive outcomes. Given the need for such training, we created a novel approach in which a series of six carefully scripted interactive scenarios was developed incorporating highly trained actors serving as the subjects, followed by feedback and group discussion. We describe this training, including problems encountered during these sessions, and examine qualitative feedback from police officers and actors about its impact and acceptability.
Methods
Both the University of Alberta Research Ethics Board and the Edmonton Police Service's Chiefs Committee approved this research. Written informed consent was received from all members of the Edmonton Police Service (EPS) who took part in the study.
The study sample was EPS officers who were taking part in quarterly training programs (n = 663). Qualitative feedback from online surveys of officers (n = 381) and the professional actors (n = 9) is described. The participants were asked to detail their opinions anonymously regarding the mental health role-play training. The officers averaged 32 years of age, more than 80 percent had been officers for less than 5 years, and nearly 75 percent had some form of postsecondary or graduate training (Table 1).
Police officers were trained in groups of 30 to 50 individuals during nearly 20 separate training sessions over a two-month period.
Scenarios
The six scenarios represented a variety of situations in which police officers are likely to be involved (Table 2). They were as follows: depressed suicidal female with a reported overdose; alcohol intoxication with likely medical problems; possible psychosis; depressed and actively suicidal individual; mania with possible drug use and physical symptoms; and domestic dispute precipitated by problem gambling. Each scenario had a series of components for everyone involved, explaining the key goals and problems and providing feedback for the police officers. These scenarios had to be realistic and reproducible. Great care was taken in developing them to ensure that they were authentic from both psychiatric and police viewpoints. An example is given in Table 3.
Feedback to Police Officers
One of the aspects of this training that not all police officers found comfortable and that was unique among previously described training regimens: feedback was provided by the actors after each scenario. The feedback was focused, not on police behavior or tactics, but primarily on empathic and emotional factors (i.e., how the police officer made the actor feel) and how the officer could have acted differently, usually in terms of body language, to improve his show of empathy. Informing officers of their behavioral and verbal strengths and weaknesses was intended to increase their insight into the most appropriate ways of communication. The types of actor feedback revolved around the actors' complimenting good forms of body language and attentiveness (i.e., active listening with patience and focused attention, a calm and still body, eye contact, and open forms of body language). An example of actor feedback is shown in Table 4, which also demonstrates the specific features that were recorded in each scenario. It should be noted that, for each scenario, there were two actors present, one who took part and one who observed. The actors rotated through the two roles during the day, allowing each scenario to remain consistent without actor burnout. Both the participating and observing actors gave feedback.
Police officers also received reviews from multiple sources including senior police officers, civilian members of the EPS, and specialized individuals who formed part of the Police and Crisis Team (PACT). This group is a combination of police officers, psychologists, and other staff specializing in treatment of individuals with psychiatric illness. An example of senior police feedback is shown in Table 5, which also demonstrates the specific features that were examined for each scenario. Thus, there were multiple levels of feedback after each scenario that addressed different aspects of the officer's behavior. The goal of the training was to increase officers' self-awareness of behavior and to help them respond positively to individuals by increasing communication and rapport with those with whom they interact.
Daily Schedule
Each training day started with an explanation of the goals of the day. Emphasis was placed on active listening skills such as paraphrasing, emotional labeling, mirroring, minimal encouragers, summarizing, and the beneficial use of silence. Other interpersonal skills that police officers were told would be evaluated were the ability to develop rapport with the subject, the ability to de-escalate situations, the use of appropriate body language, and the ability to demonstrate empathy. In addition, the officers were told how the actors were going to give them feedback. If at any time the actor-officer interaction escalated into conflict, the experienced supervisory police officer would determine whether the scenario should be stopped.
Pairs of officers would go through each scenario, with six simultaneous scenarios being run in different locations within the same building. Each police officer would rotate through the six scenarios during the day. At the beginning of each scenario, police officers would receive information similar to that given to them before they attend a call, and they would then proceed with the scenario. After each scenario, there was a debriefing with feedback from the supervising police officer, psychiatric staff (when present), and actors.
The intensive instruction that was necessary to bring all staff to the level where a successful training program could be carried out took place over two months. The work involved in developing such a group should not be underestimated.
Measurements of Training
After each scenario, the actors and the psychiatric supervisors evaluated the experience on a Likert rating scale, and the results were summarized for each training day. The scores ranged from 1 (strongly unsatisfactory training day) to 4 (strongly satisfactory training day). This assessment included several factors, such as how officers received the instruction, their professionalism, and how they interacted with the psychiatric and civilian participants. Police officers also assessed each day's level of satisfaction, using the same scale to determine if training improved after both actors and facilitators became more familiar with the program.
After every day of training, each police officer was offered the opportunity to give qualitative anonymous feedback online. The survey evaluated four major factors regarding the training: the benefits of the session, the level of acceptance of the scenario method, the facilitator feedback, and overall training satisfaction.
The actors were offered the same opportunity after the final day of training. Feedback from actors described how they interacted with officers and facilitators, emphasizing what worked and what improvements were needed for future training. These were all explained in both positive and negative illustrative quotations.
Results
Of the 663 officers who participated in the mental health training, 381 completed the online survey, and of those, 312 completed the demographic data (Table 1).
Reported Training Benefits
In the individual feedback, the police officers reported that having actors in each scenario was the most beneficial factor in training (22%), followed by the use of role-playing scenarios (19%), having the group discussion (15%), getting feedback from the facilitators (14%), getting feedback from the actors (13%), the debriefing discussion (10%), the prebriefing introduction (4%), and scenario questions (2%). The response of the police officers was generally very positive (Table 6) with perhaps the most important finding being that nearly 50 percent strongly agreed with the statement, “I will implement the knowledge and skills learned from this course in my everyday duties.”
Increased Acceptance of Training
Throughout the training, a comparison was made between the police officers' level of satisfaction and that of the actors on a Likert Scale from 4 (strongly satisfied) to 1 (strongly dissatisfied) during each training day. The purpose of the comparison was to detect both the police officers' and actors' views of each training day and to track the level of training day improvement from start to finish. The results showed that both groups had statistically significant agreement about the success of each training day, with a correlation coefficient of r = 0.468 (p = .043). Results also showed a positive stabilization of training satisfaction after the midpoint of training, as shown in Figure 1. The overall mean for police officer satisfaction throughout the training was 3.4 (SD 0.2), and the mean for actor satisfaction was 3.2 (SD 0.7).
Comments about the acceptance of training progressively improved. The officers were asked to describe the level of opportunity that the scenarios provided for learning about mental health, active listening, and body language. They were also advised to state any new concepts learned through scenario practice and feedback. Throughout the beginning sessions of training, they had mixed opinions involving the benefits of actor feedback, with comments largely more negative than positive. For example, one officer stated, “I thought the use of actors was a good idea; however, their feedback was unrealistic and unnecessary.” Another officer affirmed, “The feedback from the actors was beneficial for being more aware of how our approach can make people feel. In saying that, certain comments on our tactics were frustrating, as they did not know how we are trained.” Despite these initially negative statements, comments about the actors' feedback eventually became consistently positive. For instance, one officer stated,
A lot of these scenarios were the same as what I have dealt with on the street. I found that I was consistent with how I was dealing with people with challenges. The feedback I received from both actors and training staff was positive and [I received] reinforcement that I was going down the correct road when dealing with these individuals.
Near the end of the training, another officer opined:
The idea of using trained actors is an outstanding one. It resulted in a scenario, which is as close as it could possibly be to an actual call. The actors took their roles seriously and they immersed themselves completely into their parts. I also found that during the debrief, the actors possessed a good deal of knowledge concerning the behaviors, characteristics and for lack of a better word, eccentricities of those suffering from mental illnesses. This knowledge was very effectively parlayed into an incredibly authentic feeling scenario. The actors provided a very valuable perspective that we historically haven't been able to capture.
Thus, the officers became more accepting of the training as time went on.
Consistent Facilitator Feedback
The officers consistently reported the facilitators' involvement as positive when asked to comment on the level of professionalism and respect conveyed throughout training. One officer stated on the first training day, “As always, members of training staff were professional, knowledgeable, and prepared.” Another officer, on the last training day noted, “It was helpful to get feedback from the facilitators as they were able to critique the scenario. Good feedback was given by all facilitators.” Throughout training, the officers' comments about facilitators were consistently positive, with the majority affirming that they had “nothing negative to say about facilitators” and that the “facilitators were professional and helpful.”
Consistent Overall Training Satisfaction
Just as feedback regarding facilitators was consistent, overall satisfaction with the training remained consistently positive, with minor negative comments throughout. As one officer explained early in training, “I like the idea of feedback and doing scenarios to assist with our abilities on the street. It was great to have both an inside police perspective and a civilian perspective of how we conduct our investigations. Effective learning.” Another officer emphasized, “I can honestly say, one of the best training days I have ever attended,” and later stated, “It's easy to conclude this training will create better police officers.” Near the end of the training days, comments such as, “This was an excellent training day that provided as close to real-world situations as possible while maintaining a safe environment. The actors were extremely professional and their input and feedback was very beneficial for the learning objectives. Excellent work by training section in implementing this training,” and, “Going into this [training] I did not think it was going to be useful at all. The idea of having actors tell me how I made them feel seemed silly. However, once we got started I quickly found value in having the actors and the group discussions. This training day was very good.” Another officer reported, “[The training] exceeded my expectations. I can see how people that did not do well in these scenarios would criticize it negatively. I hope we can do more scenarios with actors.”
Officers also described the instant benefits of the training: “Great day; of particular note, a member of my squad mentioned several days later that they had gone to a call ‘exactly like one of the scenarios.’ As such, they were able to reference what they learned in achieving a successful outcome.” Finally, one officer said:
I very much enjoyed the training day. I truly believe that we can gain more results with the public through the use of our mouths rather than fists. Although it is important to have a strong understanding in control tactics, I feel the majority of my interaction with the public rests on how I interact with them verbally rather than physically. I am grateful that we were given a day to practice our communication with the public. I especially felt it beneficial to have actors relay their perspectives and feelings to us. I feel having an “outside” perspective really gives us, as police, a better view as to what and how our “cliental” view us.
Thus, most of the comments emphasized the importance of training through this novel experience.
Negative Statements
Although reaction to the training was largely positive, negative comments were given, mainly describing the need for more information about mental illness: “scenarios were good practice; however, a little more background into the different types of mental disorders would have been beneficial rather than find[ing] out after the fact and just briefly touching on some of the symptoms exhibited”; and the belief that this training is not for veteran members: “[the mental health] training day was good for a one- to two-year member.” There were comments dismissing everything taught: “I have attempted to use the skills presented to me by the facilitators and actors in everyday mental health calls. So far, none of the tools provided to me have worked, and actually made situations worse and more difficult”; remarks on the length of the training day: “I believe this could have been condensed into a half a day. Six scenarios were too many”; and opinions (n = 5) about actor feedback: “I found it difficult to wrap my head around an actor explaining how their character felt. A schizophrenic would not likely think or feel in any way similar to what the actors ‘felt’ and this somewhat made the scenario's unrealistic.” Despite these negative opinions, the positive comments heavily outweighed the negative ones.
Actor Feedback After Training
For individual feedback, the actors were given questionnaires after training (n = 9).
Feedback from the actors was generally very positive (Table 7), with important feedback emphasizing that 78 percent of the actors strongly agreed with the statements: “The officers treated me with respect throughout the training” and “The facilitators were professional and treated all of the actors with respect.” Despite this, only 33 percent of the actors strongly agreed with the statement that “It was easy to give feedback to the police because [the actor] felt prepared and knowledgeable in what [the actor] was wanting to say.”
The actors' opinions improved over time. One stated, “I felt especially nervous about giving feedback at the beginning of [training]; however, I eventually grew into giving it.” Another confirmed that, “I think almost all of the actors would agree that the back half ran much better than the front half, due to the feedback given by all parties involved through the training process.”
There were minor problems regarding the way the officers treated the actors, “For the most part, the sworn-in members did treat us with respect; some of the officer trainees, however, I felt did not.” An actor commented:
There were a select few [officers] who didn't treat the training seriously; however, all of the other officers were amazing. They were respectful and listened to my feedback. One officer even asked us questions about our scenario conditions and empathy demonstrating how much he respected our knowledge and opinions.
Despite this, the view of the training as a whole was consistently positive. An actor opined, “I really do believe this kind of work can have such a positive impact on the way the police are viewed by the public. I know my opinions have changed drastically, just over the two-month period!” From another actor, “I enjoyed the experience. I feel overall the training was a success. We even had a squad leader who was negative coming in say that he had been converted and found the training beneficial.”
Regarding the training goals, another actor stated positively:
The overall outcome was great. I feel the officers did learn some important points about mental [health]. Regarding empathy, I feel the officers were able to take home some important points from the experience. I also feel the relationships and interactions they had with the actors, as civilians, may have helped to personalize some civilians and I hope they take this understanding with them into everyday interactions.
The actors' recommendations for future training emphasized two factors: improve actor training for giving effective feedback and have a consistent police facilitator throughout each scenario, who forms a mutually respectful relationship with the actors. The first recommendation was constantly brought up:
I think the actor feedback is by far the aspect of the training that needs to be improved most. It was very rarely that I felt my comments were actually being taken seriously from the officers, and I often felt uncomfortable giving feedback, knowing that they weren't listening and/or didn't care.
Another actor responded, “Information we, as actors, relayed to the police (both the trainees and sworn-in members) carried, inherently and predictably, less significance and weight than information relayed by other police officers.” Regarding the recommendation that facilitators stay constant, in the scenarios where this occurred, there was a significant increase in the ability of the actors to give meaningful feedback to the officers and their remarks appeared to be better accepted. “I found, with [our consistent facilitator's] guidance, our scenario evolved over the duration of training and our feedback became stronger for the officers with all we had learned.” The same actor later stated, “[The] regular facilitator made the environment feel safe and I felt comfortable giving feedback; conversely, with the alternate facilitator I felt intimidated when giving feedback. I was very qualified to give feedback; yet, my confidence in giving feedback was entirely different dependent on the facilitator.” This opinion was supported by another actor, who said:
When feedback was dismissed or mocked, the outcome very much depended on a) the presence of a supervising officer and his/her attitude to the feedback in question, and b) the assertiveness, comfort level, and skill of the facilitator. When facilitators are constantly changing, they are not able to understand the scenarios fully, and thus inconsistencies arise.
The actor went on to confirm a way for improvement, “Quality and consistency of feedback was best when actors had a few moments to discuss particular concerns, experiences, thrills, etc., when needed, with the facilitator before the feedback session.”
Problems with the Scenarios and Responses to Feedback
Police culture influenced the attitudes and opinions of each police officer. Emotional insight through training is unique, and it is not currently addressed in any other training sessions. In particular, the police officers had never known how they made others feel. In this context, it was of interest that feedback from the nonsworn members (i.e., nonpolice individuals, including actors) was not as well received as that from the more senior police officers. One actor described it thus, “In very few cases, some of the interactions among the officers and the actors in the scenarios made me feel as though certain officers held a sense of nonrespect and superiority over civilians.” It was also noted that older officers found accepting feedback to be a less positive experience and showed a greater tendency to dismiss the actors' opinions. This reaction was shown by the comments from officers who thought that the training was of no benefit to them; however, they believed that “junior members would benefit more” from it.
Each scenario provoked specific responses, the most frequent of which are shown, by scenario, in Table 8.
Discussion
Although training of police officers about mental illness is becoming more widespread throughout the world, there is little documentation describing in detail what methods should be developed to produce consistent, high-quality, effective training. The present article presents details of the questions and positive aspects of the development of this novel training program. The experience revealed needs to be clarified through future research. There should be additional research to ensure that the positive outcomes and approaches used to create an effective mental health training system for police officers are maintained over time.
The method is a novel approach, using actors trained in a variety of realistic psychiatric scenarios depicting real-world experiences of police officers. The training was a time-intensive program with the future goal of changing the behavior of police officers and an emphasis on actor and officer response over time.
The present study involved a larger cohort than most (n = 663), although online responses were obtained from only 58 percent (n = 381). The results overall were very positive, with the training regimen being well received by the officers, and nearly 50 percent strongly agreeing that the training would change their interactions with persons with mental disorders. Whether this actually occurs, however, will require additional research to determine. An additional benefit from the view of the police officers, who took time away from their usual work, was that the training lasted only a single day.
The primary negative aspects of the training course were the significant time and cost of implementation and the resources involved. A large amount of training time was involved, both for the police department and the actors. The results also suggested that the effectiveness of the training increased with time, which would be consistent with the increasing comfort of the actors and supervisors with the training as they gained more experience. This outcome suggests that, particularly where many police officers or other law enforcement individuals are being trained, a group could be committed for a longer period and could retain the experience. However, the costs were significant. We chose to have two professional actors present for every scenario every day; one would observe, the other would participate directly, and then they would switch. It is uncertain how necessary having two actors is; using a single actor would decrease the cost. Using rates from published agreements with actors, and training 30 officers per day, the cost amounts to only $60 per officer when one professional actor is present in each scenario. It should be noted, however, that this cost does not include setup and preparation, and it also does not include having police supervisors involved in the training session, because they were full-time members of the training section of the EPS, and no additional costs were actually incurred.
Despite the negative implication of cost, the positive outcomes were such that this form of interactive, hands-on, role play training, in which police officers learn from actors who become very experienced in the specific scenario, does seem quantitatively different from other forms of training recommended to date. Future research should determine the effectiveness of this training method by measuring the interaction of police officers with the mentally ill and quantifying the cost versus benefit. A cost-benefit analysis is very important, given the significant costs of the program for large police forces. This area is an important one for future research, as the ability to show that such training is cost-effective is critical. Similarly, evidence that such training influences on-going attitudes and behaviors is also important, and subsequent research should be conducted to examine this subject.
In conclusion, this novel training method focused on increasing the communication skills of police officers, particularly on improving active listening and empathy. Feedback on the experience from both officers and actors was very positive. Further research is needed to determine the impact of the training on behavior.
Acknowledgments
A large number of Edmonton Police Service (EPS) staff from the training group worked extremely hard to ensure the success of this novel training approach. The research team is very grateful and would like to acknowledge their help. They would also like to acknowledge with gratitude the willingness of the EPS senior management to commit significant resources to a novel form of training.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2013 American Academy of Psychiatry and the Law