Introduction

In August of 2016, 36-year-old, Joseph (Joey) Weber, was apprehended by a police officer. Initially, Weber was stopped for improper tag display and an expired decal. However, this traffic-stop soon turned into a car chase and later a pursuit on foot. After the police officer chased Weber and finally tackled him, Weber reportedly began wrestling with the officer for his gun. In fear for his life, the officer pressed the gun to Weber’s chest and shot him, ending his life (Schwein 2016). As the investigation went on, it was revealed Weber was receiving treatment for Autism Spectrum Disorder, an anxiety disorder, Intermittent Explosive Disorder, and was diagnosed with a mild intellectual disability. Further investigation revealed Weber was not armed (Matthews 2016).

Following Weber’s death, Joey’s Law was passed in the state of Kansas. This law allows individuals to receive special identification (e.g., license plate decal) to alert law enforcement officers of any disabilities or diagnoses (Aguilar 2017). Joey’s Law was passed with the goal of averting fatal outcomes from occurring by notifying officers to take caution before situations escalate—individuals struggling with a mental illness may experience heightened anxiety with flashing lights and loud noises or commands. Joey’s Law provides a preemptive signal to officers, allowing them to be wary in their approach and interactions with those who have a mental illness. However, concern about Joey’s Law is the potential for law enforcement officers to negatively profile or intentionally target these individuals as a result of stigma surrounding mental illness.

Stigma of Mental Illness

Mental health stigma refers to negative attitudes held toward individuals who suffer from a mental illness (Corrigan and Watson 2002). These prejudices manifest through stereotypical beliefs, fear, and lack of empathy toward individuals with a psychological disorder or presenting symptoms—individuals with a mental illness are often perceived as increasingly violent or dangerous (Varshney et al. 2016). Unfortunately, stigma and bias toward mental illness may cause individuals with a psychological disorder to be viewed or treated differently when interacting with law enforcement (Watson et al. 2004). Although escalated or criminal behavior displayed by these individuals may be a manifestation of mental health–related symptoms or unmet treatment needs, some prior literature suggests law enforcement officers may resort to arrest during these encounters (Hails and Borum 2003).

Law enforcement mental health training increases officer understanding of mental illness in the community (Bonfine et al. 2014). However, officers in most jurisdictions receive only eight hours of mental health training to outline a basic understanding of psychological disorders and how to successfully interact with those experiencing them (Police Executive Research Forum 2015). Instead, law enforcement officers are inevitably permitted use of their own discretion during arrests and encounters (Gerstein and Prescott 2014; Lamb et al. 2002). In turn, the potential for law enforcement responses to be influenced by personal attitudes or beliefs increases (Lamb et al. 2002). Officers have been found to arrest individuals with a mental illness more frequently (Lamb et al. 2002) or perceive them as more dangerous (Watson et al. 2004) compared with those without presenting symptoms. In fact, law enforcement officers acknowledge both fear and uncertainty surrounding persons with a mental illness are a result of stigma surrounding mental illness (Bonfine et al. 2014). However, little is known about how the role of stigma may impact law enforcement officers working in rural agencies, as previous literature focuses primarily on urban policing (Pelfrey 2007; Yang et al. 2018).

Mental Health and the Heartland

The term “rural” can be defined in a variety of ways and has been debated among various sources. Literature suggests over a dozen definitions have been utilized interchangeably by researchers and policymakers, speaking to the complexity of the term (Cromartie and Bucholtz 2008). The United States Census Bureau utilizes a dichotomous definition of urban and rural, describing any population not in an urban territory those with 2500 persons or more—as rural. The Kansas Department of Health and Environment (KDHE) services divides counties into five different criteria based on persons per square mile: frontier, rural, densely settled rural, semi-urban, and urban. At the time of the 2010 census, approximately 60 million individuals resided within rural communities, which made up about 19% of the US population and surpassed the numbers of any minority group in the USA (Weisheit and Donnermeyer 2000). Despite the majority of the population residing in urban areas, most places in the USA are rural, making up almost 70% of the country.

The heartland state of Kansas spans over approximately 82,000 mile2 with an estimated population of 2,911,505 (Census Bureau 2018). Of these individuals, 919,264 reside in communities considered to be rural—majority of the counties within the state can be classified as either densely settled rural, rural, or frontier based on KDHE classifications. County classifications for the state of Kansas can be seen on Fig. 1.

Fig. 1
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Population density in Kansas by County, 2018

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Following the 1990 Kansas Mental Health Reform Act, the state shifted to a predominately community-based model of mental health care (Kansas Health Institute 2017). With this shift came the closing of several inpatient mental health facilities. Thus, the number of inpatient psychiatric beds decreased drastically with more individuals receiving outpatient services. While this shift reduced expenditures in psychiatric hospitals, a healthy balance between the supply of inpatient beds and the demand for inpatient beds has yet to be achieved. Instead, the number of people on the waiting list for facilities increased.

Rural Law Enforcement and Mental Illness

Many rural communities continue to struggle with the hardship of providing mental health services (Jameson and Blank 2007; Terry 2018; Thomas et al. 2012). As such, law enforcement officers are often tasked with compensating for these shortcomings, resulting in officers responding to an increasing number of mental health calls and crises (Russell 2016; Weisheit et al. 2006) and with identifying treatment resources and outcomes for individuals struggling with a mental illness (Donnermeyer et al. 2011). Previous literature suggests rural communities are at a heightened risk of stigma toward mental illness (Murry et al. 2011). Despite this, the small amount of literature existing on rural law enforcement perceptions of mental illness has been mixed, with some studies revealing negative feelings toward working with those with a mental illness (Murry et al. 2011), and others suggesting overall positive perceptions (Yang et al. 2018). While use of force data suggests these incidents to be generally low in all areas, use of force remains disproportionately higher on rural mental health related calls (Yang et al. 2018). These discrepancies suggest a need for improved exploration of rural law enforcement perceptions of mental health. Urban research has found many law enforcement officers expect violent and abnormal behavior when encountering individuals displaying symptoms of a mental health disorder (Gillig et al. 1990; Hansson and Markström 2014; Watson et al. 2004). Yet, it is unknown if this is the case in more rural locations.

Since deinstitutionalization, efforts have been made to help successfully integrate discharged individuals with mental illness back into communities across the USA (Enbar et al. 2004; Kruzich 1985). However, throughout the last 20 years, research has shown public attitudes have not changed, as discrimination and stereotyping toward mental illness remain common (Angermeyer and Matschinger 2003; Bathje and Pryor 2011; Schomerus et al. 2012). Instead, the relationship between the criminal justice system and individuals with a mental illness has intensified throughout recent years (Brink et al. 2011; Tully and Smith 2015). For example, approximately 7–10% of all police encounters involve individuals with a mental illness (Akins et al. 2016; Hails and Borum 2003). In one study, majority of rural officers (80%) reported interacting with a person with a mental illness at least once per week (Yang et al. 2018). Still, little has been done to assess whether officers hold inherently negative perceptions of those presenting with mental health problems or if outside variables are driving tenuous relationships between law enforcement and those struggling with mental illness.

The Current Study

Literature suggests law enforcement professionals, namely police officers, provide up to one-third of mental health services in the USA (Vermette et al. 2005), with an even greater rate provided by rural officers (Murry et al. 2011; Yang et al. 2018). Despite the frequency of these situations, officers receive minimal amounts of mental health training (Hails and Borum 2003; Police Executive Research Forum 2015), and rarely receive further training in this area. Generally, research on police interactions has focused primarily on urban populations, discounting unique rural components (Pelfrey 2007; Yang et al. 2018). What literature does exist provides inconsistent findings on rural law enforcement perceptions of those with mental illness. The current study expands on literature surrounding mental health stigma among rural law enforcement officers. Due to the prevalence of law enforcement encounters and experiences involving a mental illness, it is necessary to consider how rural officers view their own training as well as their views on mental health as a whole. The current study explores present views held by officers in the heartland state of Kansas.

Method

Participants and Procedure

Participants included 62 law enforcement officers (54 men, 8 women; M age = 40.00, SD age = 12.86) from six agencies across the state of Kansas. The average time spent working as a law enforcement officer was 134.37 months (median = 79.50), or approximately 11 years. The majority of participants (98.4%) identified as Caucasian, with one individual identifying as Hispanic (1.6%). Education levels of those law enforcement officers surveyed included high school/GED (6.6%), some college (49.2%), a bachelor’s degree (41%), and graduate/professional degree (3.3%). All IRB and APA regulations were strictly followed during the data collection process and maintenance of data. Researchers took special care to eliminate officer rank from survey questions to protect anonymity of participants.

Law enforcement agencies were contacted by phone and/or email by the research team to gauge interest. Agencies were given the opportunity to arrange in-person meetings to discuss participation in the project. Those agencies interested in participating in the survey were asked to provide verbal consent and were then given an online questionnaire link via Survey Monkey to share throughout the agency. Individual officers were asked to provide consent prior to completing the questionnaire, after which they were debriefed. Law enforcement officers responded to a series of demographic questions (e.g., age, gender, ethnicity) and completed two previously validated questionnaires assessing views on mental illness. The current study is part of an ongoing study on mental health stigma present in Kansas; thus, scale items were chosen to allow for comparison between this sample and others (e.g., juvenile justice-involved youth, correctional staff). Several self-constructed questions were included to supplement this material.

Materials

Attitudes about Child Mental Health Questionnaire (ACMHQ)

Participants completed an adapted version of the Attitudes about Child Mental Health Questionnaire (ACMHQ) (Heflinger et al. 2014). This scale consists of 30 items designed to assess various aspects surrounding mental health stigma. Questions on the scale are broken into four categories: Dangerousness/Incompetence, General Stereotypes, Community Devaluation/Discrimination, and Personal Attitudes. The internal consistency of these subscales (measured by Cronbach’s alpha) is high (ranging from .78–.94). Items on the scale are measured on a 6-point Likert scale (1 = Strongly disagree; 6 = Strongly agree). Although this scale was originally intended to measure perceptions toward youth with mental illness, scale categories are beneficial in assessing law enforcement perceptions for the current study. Questions were adapted from the original scale to include perceptions of individuals with a mental illness, rather than focusing on youth. An adapted example item from the scale include the following: individuals with a mental illness are not as smart as other individuals.

Mental Health Knowledge and Attitude Test (MHKAT)

The MHKAT (Penn et al. 2005) is a 12-item scale designed to assess individual knowledge and attitudes toward mental health needs. Law enforcement officers in the current study completed an adapted version of the questionnaire to assess their views on staff mental health training and resources as a whole. Items on the adapted scale were measured on a 5-point Likert scale (1 = Strongly disagree; 5 = Strongly agree). An adapted example item from the scale includes the following: individuals with a mental illness use suicide to manipulate law enforcement.

Results

Mental Health Experience and Knowledge

Nearly half (46.8%) of the law enforcement officers surveyed indicated having some previous career experience working with individuals with a mental illness. While the majority (87.1%) of the officers reported no mental health diagnosis of their own, over half (56.5%) reported knowing someone personally who has been diagnosed with a mental illness. Officers reported feeling they were neutrally to somewhat knowledgeable about mental health issues (M = 2.23, SD = .80) and about offenders with mental illness in the criminal or juvenile justice system (M = 2.11, SD = .73). Officers also reported at least neutrally to somewhat agreeing they had received adequate training for managing individuals with a mental illness (M = 2.79, SD = 1.14). However, officers also neutrally to somewhat agreed the use of force increases when encountering individuals with a mental illness (M = 2.66, SD = .87).

Additionally, overall mean scores on the MHKAT indicated officers somewhat to strongly agreed with questions assessing their mental health knowledge (M = 1.87, SD = .42). Mean scores were calculated for individual items on the scale. Officers neutrally to somewhat agreed individuals in the juvenile and criminal justice system demonstrate more escalated mental health behaviors than individuals not in the system (M = 2.46, SD = .87) and that increased mental health resources decrease law enforcement encounters with individuals with a mental illness (M = 2.29, SD = .93). Officers somewhat to strongly agreed responding officers take threats of suicide seriously (M = 1.42, SD = .78), suicidal individuals should be referred for psychological evaluation (M = 1.27, SD = .58), and mental health screening and ongoing assessment is important in suicide prevention (M = 1.35, SD = .75). Finally, officers indicated somewhat to strongly agreeing training and communication for law enforcement officers is important in suicide prevention (M = 1.31, SD = .75), that there is a need for increased mental health treatment for individuals in the criminal and juvenile justice systems (M = 1.81, SD = .77), and that there is a need for community mental health resources (M = 1.37, SD = .63).

Mental Health Stigma

Officer scores on subscales of the ACMHQ indicated overall positive views of mental illness. On the Dangerousness/Incompetence subscale, officers reported feeling either neutral or somewhat disagreeing with stigmatic statements about mental illness (M = 3.60, SD = .75). Neutral to somewhat disagreement was also reported for the Community Devaluation/Discrimination subscale (M = 4.14, SD = .57). Furthermore, officers indicated somewhat to strong disagreement with items on the General Stereotypes (M = 4.14, SD = .57) and Personal Attitudes (M = 4.25, SD = .68) subscales. Mean scores for each of the stigma subscales can be found on Table 1.

Table 1 Mean scores for stigma measure
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Simple linear regressions were conducted to further explore the relationship between mental health stigma and officer use of force. Interestingly, Community Devaluation/Discrimination was found to be significantly predictive of the likelihood of using force increasing when encountering individuals with a mental illness, β = .39, t(61) = .26, p = .053. The less likely officers were to endorse stigmatic views about individual community devaluation or discrimination, the less likely they were to agree use of force increased when encountering an individual with a mental illness. Additionally, the Dangerousness/Incompetence subscale was found to be a marginally significant predictor of use of force, β = .30, t(61) = 1.99, p = .05. The General Stereotypes and Personal Attitudes subscales were not found to be predictive of views on use of force.

Limitations

The current project is not without limitations. By design, results from the study were collected only within the state of Kansas. Although anticipated, there was a limited number of respondents to the survey which resulted in a sample lacking ethnic diversity. Although many agencies across the state of Kansas were contacted and asked to participate, only a handful resulted in officer survey completion. Future studies should assess areas of stigma, law enforcement knowledge, and training perceptions in other locations throughout the USA and in more diverse locations. Continued research should be completed in rural areas to allow for comparisons to be made between urban versus rural agencies.

Second, researchers failed to include an objective measure of mental health knowledge when surveying officers. Officers were asked to indicate their perception of their own mental health knowledge. However, those officers indicating strong knowledge were not assessed to determine if this perception is accurate in terms of actual understanding of psychological disorders. Future studies should first examine officer comprehension of mental health to compare with their self-reported knowledge.

Discussion

The current study begins to address understudied rural law enforcement perceptions of mental health. Despite reported knowledge of both mental health as a whole and mental health within the criminal and juvenile justice systems, officers of the current study continue to support the need for increased mental health training. Further, during in-person meetings and phone interactions, rural law enforcement officers and members of the research team spent time engaging in unscripted discussion surrounding the quality of mental health services in relation to their career. Some officers shared stories of specific individuals in communities who displayed escalated mental health symptoms over time with little to no improvement; however, other agencies described improved working relationships between themselves and local mental health services.

Discussion surrounding overspending of local jails on psychiatric medication was prevalent, with reports of lacking options for care of individuals with a mental illness mentioned by all agencies and matching survey responses. Officers push for increased mental health resources within their community—a finding consistent with previous literature in rural communities (Thomas et al. 2012). The responsibility placed on the criminal justice system for meeting the needs of individuals with mental illness may sometimes feel burdensome (Ranney 2014), especially for those law enforcement officers in rural locations (Murry et al. 2011; Yang et al. 2018). Many conversations with police chiefs and sheriffs revealed frustration over lack of adequate community resources to appropriately treat individuals with mental illness and a strong desire for additional training, consistent with research indicating rural agencies must make use of limited resources across large geographic regions (Baird-Olson 2000; Ricciardelli 2018; Yang et al. 2018).

Although the current study revealed some lacking aspects of rurality when attempting to provide adequate mental health services, findings from the current study also shed light onto positive rural law enforcement perceptions of mental illness within the state of Kansas. Results suggest rural law enforcement officers are generally not stigmatic toward those with a mental illness—a finding inconsistent with some previous literature on rural communities (Murry et al. 2011) but matching attitudes revealed more recently by others (Yang et al. 2018). In the current study, officers revealed minimal general stigma or negative personal attitudes toward mental illness, indicating they tend to disagree that individuals with a mental illness are trouble, cannot be successful, or should be avoided. Additionally, officers disagreed with statements indicating individuals with a mental illness should be viewed as incompetent or dangerous.

Previous research indicates stigmatic attitudes are linked with behavioral outcomes and lower generalized stigma leads to greater empathy and benevolence (Fazio and Roskos-Ewoldsen 2005; Kenny et al. 2018). As the officers in this study tend to show lower levels of prejudiced attitudes, they may be more likely to demonstrate empathy and compassion when dealing with individuals with mental illness (Inzunza 2015). This demonstration of understanding and empathy is an important component in policing as it may lead to a greater ability to recognize signs and symptoms of mental illness, an increase in utility of mental health services, and overall better relations between law enforcement and the community (Hanafi, Bahora, Demir, and Compton 2008; Holmberg 2002, Munetz, Grande, and Chambers 2001). These findings on the relationship between stigma of mental illness, empathy, and policing provide insight into officer compassion and positive response—aspects that appear often overlooked in today’s society.

Stigmatic views have an influence on increasing discriminatory behaviors such as withholding help, violent treatment, or avoidance (Corrigan et al. 2001; Corrigan and Watson 2002). The findings of the current study regarding officer perceptions of mental illness in regard to perceived use of force are valuable and may indicate lower stigmatic views lead to less serious actions when encountering an individual with a mental illness. Regression results show the less discriminatory views officers hold, the less likely they are to believe use of force increases for persons with a mental illness. This trend was also observed for perceived dangerousness surrounding those with a mental illness. While these findings explore only perceptions of law enforcement and use of force, they remain hopeful given that data tend to show an increase in use of force in rural mental health related calls (Yang et al. 2018).

While it is imperative to examine tragic or violent encounters between law enforcement and individuals struggling with a mental illness, what may be more necessary is to examine why these events continue to occur. Depleted budgets and limited available options continue to serve as a barrier for increased mental health training for law enforcement as several agencies spoke to the limited budget for mental health training and discussions centered around the desire for improved training, treatment, and mental health resources in all rural counties surveyed. Efforts must be made to address all-encompassing issues in America as a whole—underfunding and limited discussion surrounding improved ways to address mental health needs.