“We’re Not the Cure, We’re Just the Band-Aid”: The Interplay of Structure, Culture, and Practice in Police Service Provision to Persons with Mental Illnesses

• Published date: 01 April 2023
• DOI: http://doi.org/10.1177/02750740231165012
• Author: Galia Cohen
• Date: 01 April 2023
• Subject Matter: Articles

“We’re Not the Cure, We’re Just the

Band-Aid”: The Interplay of Structure,

Culture, and Practice in Police Service

Provision to Persons with Mental Illnesses

Galia Cohen

Abstract

This study uses the constellation approach of transition theory as a theoretical framework to depict the ways in which facil-

itators and barriers in police system’s structure, culture, and practice interact to shape police response to persons with men-

tal illnesses (PWMIs). The study utilizes the framework method to analyze 57 in-depth interviews with police off‌icers in Texas.

Using a hybrid approach of inductive and deductive thematic analysis, we develop a matrix of four quadrants characterizing the

constellation of mental health service provision by police: (1) structural barriers (def‌icits in resources, unsuccessful collabo-

ration, lack of training), (2) structural facilitators (crisis intervention teams, informal cross-disciplinary collaborations, technol-

ogy), (3) cultural barriers (role conf‌lict, perceived inability to help, stigma), and (4) cultural facilitators (the police

mission ‘to serve and protect’, improving police public image, managerial support). The study ends with recommendations

for the scaling up of police mental health service provision to PWMIs.

Keywords

police, mental illness, transition theory, culture-structure-practice, street level bureaucrats, snowball sample, content analysis

Introduction

“What we are expected to do –is beyond our ability to deal with

…we’re not the cure, we’re just the band-aid …the mental

health system is broken, and we’re caught holding the bag …

we are your [society] fallback”(Interviewee #20).

Mental illnesses represent one of the top causes of disabil-

ity in the U.S., with nearly one in f‌ive adults (21%, 52.9

million) suffering from some type of diagnosable mental dis-

order (National Institute of Mental Health, 2022). In the face

of these mounting numbers, especially during the COVID-19

pandemic (e.g., Lee et al., 2021), police have become a

pivotal player in providing mental health services to individ-

uals experiencing mental health emergencies (Watson et al.,

2021).

The central role of police in servicing people with mental

illnesses (hereafter, PWMIs) is not new and has been histor-

ically controversial (Cotton & Coleman, 2010). Early works

by Buss (1995) and Fogarty (1989) have noted how deinsti-

tutionalization laws and policies in the early 1960s created

challenges in balancing the law enforcement and the social

service functions of policing. In the last decade, twenty-f‌irst

Century Policing reforms, such as developing procedural

justice training and implementing specialized mental health

response teams, have anchored police as the primary non-

medical resource for mental health services in communities

(Hirschi, 2022).

The notion that mental health response is a core police

duty (Sced, 2006) is unsurprising. After all, police off‌icers

are street level Bureaucrats (SLBs) who stand at the frontlines

of public service (Lipsky, 1971), and as such, although not

mental health experts, they are also the frontline response

to PWMIs (Alpert, 2015). According to Livingston (2016),

police are involved in the care of one-third of people with

mental illnesses in the United States.

With that said, perhaps more than any other group of

SLBs, police off‌icers possess a wide discretional freedom

(Bittner, 1970) to make decisions that impact the delivery

of public policies to the citizenry (Lipsky, 1971). In the

case of mental health calls, police interactions with PWMIs

are complex in nature, and the decisions that off‌icers make,

Department Head and Assistant Professor of Public Administration,

Tarleton State University, Fort Worth, TX, USA

Corresponding Author:

Galia Cohen, Department Head and Assistant Professor of Public

Administration, Tarleton State University, 10850 Texan Rider Dr.,

Fort Worth, TX, USA.

Email: cohen@tarelton.edu

Article

American Review of Public Administration

2023, Vol. 53(3-4) 99–114

© The Author(s) 2023

Article reuse guidelines:

sagepub.com/journals-permissions

DOI: 10.1177/02750740231165012

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sometimes in split seconds, can have a long-term impact on

PWMIs’lives (Lockwood et al., 2021).

For example, scholars found that PWMIs’encounters with

police increase their likelihood of being arrested and entan-

gled in the legal system, even if they are not committing a

crime (e.g., Watson et al., 2021). Others have found that

such encounters have more potential to become violent and

end in tragic injuries or deaths (e.g., Reuland et al., 2009).

The statistics here are outdated and inconsistent, but the

most recent available data suggests that 25% of all fatal

police shootings in the U.S. involve PWMIs (Kindy &

Elliott, 2015).

Recently, publicized and controversial police use-of-force

incidents involving PWMIs have placed a heightened focus

on police response to mental health calls, questioning off‌i-

cers’ability to handle situations involving such individuals

(Tully & Smith, 2015) and calling for a reform in police

service provisions (Watson et al., 2021). As the responsibility

for mental health concerns continues to shift towards law

enforcement, it becomes crucial to study the system of

police response to PWMIs and the factors that facilitate or

inhibit its success.

In this study, we use transition theory, specif‌ically the con-

stellation approach described by van Raak (2010, 2016), as a

theoretical framework to depict the interplay between struc-

ture, culture, and practice in police service provision to

PWMIs. Specif‌ically, we ask:

1. What factors hamper police service provision to PWMIs

in terms of the dominant structure and culture of the polic-

ing system?

2. What factors facilitate police service provision to PWMIs

in terms of the dominant structure and culture of the polic-

ing system?

3. Can identifying these barriers and facilitators provide a

basis for developing effective strategies to scale up

police service provision to PWMIs?

Identifying these factors is essential for facilitating a transi-

tion in the police service provision system. It would give

police leaders and policymakers a better understanding of

which barriers must be addressed and which pathways

should be further explored.

Literature Review

Theoretical Framework: Understanding Constellations

in Transition Theory

Transition theory emerged to explain why organizational

changes occur and what processes drive them. Rotmans

et al. (2001) def‌ine a transition as: “a gradual, continuous

process of change where the structural character of a

society (or a complex sub-system of society) transforms”

(p.16). They posit that transitions result from complicated

and persistent problems deeply rooted in societal systems

(Rotmans et al., 2001). More specif‌ically, the theory offers

a theoretical framework from which transitions in complex

systems are analyzed through fundamental changes in that

system’s dominant structure, culture, and practices

(Loorbach & Rotmans, 2010).

According to transition theory, each societal system is

made of a multitude of nested, competing, and complement-

ing constellations (van Raak, 2016) that def‌ine and fulf‌ill

their role in the larger system (Wiertsema et al., 2021).

Within a constellation, three elements: structure, culture,

and practice (hereafter, SCP), continuously interact in a

process that ultimately leads to a change in the system.

Structure refers to institutional, physical, economic, and

other arrangements that inf‌luence members’behavior

within a constellation (Pellekooren et al., 2022). Examples

of structures include but are not limited to rules, regulations,

and law (i.e., institutional), infrastructure, technologies, and

resources (i.e., physical), f‌inance, consumption, and produc-

tion (i.e., economic) (Heemskerk, 2020).

Culture pertains to members’shared norms, values, and

perceptions within a constellation that shape actors’perspec-

tives on the structures and practices of the system (van der

Ham et al., 2013). Finally, practice relates to the activities

undertaken within a constellation, such as the daily routines

and practices of the members involved in the system

(Pellekooren et al., 2022; van der Ham et al., 2013).

Simply stated, while structure emphasizes the ways actors

organize the things they do, culture focuses on the ways

actors think about the things they do and practice on what

actors actually do (Motiwala & Ezezika, 2021).

In the “structure, culture, and practice triplet”

(Loorbach & Rotmans, 2010), all three elements interact with

and adapt to each other (Pellekooren et al., 2022) in a way

that hampers and/or facilitates a change in the constellation(s).

This may eventually lead to a long-term, fundamental transition

within the entire system (Loorbach & Rotmans, 2010). The

driving force behind these changes is usually the “actors”in

the constellation and their collective sense of urgency for

change (Wiertsema et al., 2021). According to Rotmans et al.

(2001), these complex societal problems cannot be solved in

the short term, and the changes needed to resolve them

require long-term processes that last at least one generation.

Transition theory, specif‌ically the SCP model withinit, has

been widely applied to a wide range of societal systems, such

as agriculture, economics, and especially healthcare systems,

to show how these elements operate within a constellation

to induce system-wide change in organizations and improve

overall service delivery. For example, Ebuenyi et al. (2020)

explored barriers and pathways to the inclusion of persons

with mental disabilities in educational programs. They found

that barriers related to underlying structure and culture

issues signif‌icantly impede the practices of inclusion of

persons with mental or intellectual impairments into educa-

tional programs.

100 American Review of Public Administration 53(3-4)