‘All the Systems Failed’: Inside America’s Mental Health Crisis

In early 2020, Juston Root’s condition was deteriorating. 

Diagnosed with schizoaffective disorder as a young adult, the 41-year-old wasn’t taking his medicine, and those around him were concerned. His family felt that he should be civilly committed. His psychiatrist described him as “actively psychotic with poor self care,” according to a Jan. 6, 2020 evaluation. “He is not at acute risk and cannot be hospitalized against his will at this time but given his history we believe hospitalization is very likely.”

On a brisk, damp morning one month later, Root drove himself to Brigham and Women’s Hospital, part of the Boston medical center complex that also houses the Massachusetts Mental Health Center — he was in need of help. A security guard was the first person to interact with Root and radioed in a description of him after a bizarre conversation, noting that Root had a transparent object that looked like a gun. The Boston police arrived, and fewer than 10 minutes later, Root was dead, shot at least 31 times by the officers. The plastic paintball gun Root carried was never fired.

“The system failed him. All the systems failed,” said Jennifer Root Bannon, his sister. “If this can happen sandwiched between two mental health facilities, you’re not safe anywhere.”

‘All the Systems Failed’: Inside America’s Mental Health Crisis

In the months following Root’s death, his sister has sought accountability and answers about the circumstances of that day. Since May, her pursuit inadvertently dovetailed with a more national reckoning, after a searing video of George Floyd pleading for his life on a Minneapolis street corner as an officer knelt on his neck spread widely. Protests filled the streets.

But while the killings of Floyd and Breonna Taylor once again exposed deep-seated racism in American policing, the shooting of Root, who is white, underscores another systemic problem: a broken mental health system at a time when more people are in need of services than ever before. Cities have tried to better respond to mental health crises after a summer of demonstrations, but the steps taken so far are scattershot and do little on their own to prevent critical encounters with police.

The coronavirus pandemic introduces new urgency to repairing these fissures, as psychological strains on the population grow. According to a December Census Bureau poll, 42% of adults reported dealing with symptoms of anxiety and depression; nationwide EMS call logs show mental and behavioral health-related calls spiked once the pandemic and associated lockdowns began. And since Root’s death, almost 1,200 people have been killed by police, according to Mapping Police Violence

“We know that the more often you let someone deteriorate until they're in crisis, the more difficult it is to get them better, and the more likely it is for them to have bad outcomes,” said John Snook, director of government relations and strategic initiatives at the National Association for Behavioral Healthcare. “If it was any other illness we would say this is crazy, but because it's mental illness we allow it to happen.”

Health History

Root’s visit to the hospital on Feb. 7, 2020, wasn’t his first encounter with law enforcement. Nearly a year prior to his death, he drove to a police station and told officers there he was heavily armed. But instead of being met with bullets, he was hospitalized and flagged in the city’s mental health responder database. From there, he had few options for care. 

The reason can be traced back in part to a push for deinstitutionalization that came in the latter half of the 20th century. Psychiatric hospitals that operated under inhumane conditions were shuttered, but few systems were developed in their place. Today, hospital bed shortages mean that in many states, patients that make it to the hospital are often stuck in a revolving door,  getting released quickly, only to relapse. Jails and prisons became the new institutions.

‘All the Systems Failed’: Inside America’s Mental Health Crisis

By default, that’s made police a common point of contact for those who fall through the gaps in the U.S. mental health care system. Police nationwide spent about a fifth of their time responding to mental health calls, at a cost of $918 million, in 2017, according to the Treatment Advocacy Center. This means officers are often tied up with calls that they may not be well equipped to handle. Roughly a quarter of people fatally shot by police in the U.S. each year are individuals in mental health crisis, according to an August report by the National Association of State Mental Health Program Directors. 

The Root family’s home of Massachusetts is one of eight states to receive a failing grade for its mental health care system from the Treatment Advocacy Center, in part because the threshold for getting crisis care is so high: It is one of three states with no law allowing for outpatient civil commitment, one of four states that requires a risk of unreasonably severe harm to self or others to prompt civil commitment, and has no standard that allows for interventions based on past behaviors with an eye on preventing foreseeable relapses. Legislation that would change Massachusetts policy to allow for outpatient civil commitment periodically gets introduced by state lawmakers, but has thus far failed to take hold — in part because some advocates oppose involuntary hospitalization of any kind. Those constraints limit potential treatment options and make it harder to get care before cases escalate.

Alternate Models

For now, many of the interventions set up to stop tragedies like Root’s start and end with limiting the role of law enforcement in response to mental health issues.

Cities like Denver have chosen to double down on teams that pair police officers with co-responder teams of social and healthcare workers in the past year. Other cities, like Greenville, North Carolina, St. Petersburg, Florida, St. Louis, Missouri, and Chicago are piloting or launching new ones.

‘All the Systems Failed’: Inside America’s Mental Health Crisis

And there’s also a push for programs that cut out the police presence more completely, building off of the example set by Crisis Assistance Helping Out on the Streets, a program launched in Eugene, Oregon in 1989 in which 911 dispatchers in the city are trained to route calls that involve non-violent substance abuse, homelessness or mental health issues to a team made up of one EMS officer and one social worker. They typically work alone, only calling police for backup in 1% of cases, and estimate that they’ve saved the city $22 million on public safety and hospital costs. During Minneapolis’s budget deliberations, city council members chose not to expand the city’s existing co-responder model, instead dedicating additional resources to police alternatives like violence interrupters. New York City just launched a pilot program making EMS and crisis workers the default for most mental health-related calls.

These models are an improvement on the status quo, said Lisa Dailey, acting executive director of the Treatment Advocacy Center. By many metrics, they work to limit the interactions between police and people: According to a six-month progress report on Denver’s year-old police-free community response pilot, called STAR, none of the 748 mental health-related and welfare check calls health workers responded to required police backup, and none led to arrests. But to be engaged they still rely on split-second decisions, either on the part of 911 dispatchers or on the part of police officers on the scene.

“Before something escalates to become a psychiatric crisis that requires a 911 call, there are almost always a couple of opportunities — a window of opportunity — where something can be handled as a medical issue,” Dailey said. 

Just a month after Root’s death, another 41-year-old, Daniel Prude, was killed by police in Rochester, New York. Prude had been evaluated at the hospital for erratic behavior and then released just hours before his fatal encounter with law enforcement. Then, last October — weeks after announcing a co-responder model — Philadelphia police shot and killed Walter Wallace Jr., who was having a mental health crisis and wielding a knife.

In Tucson, Arizona, there’s a more holistic approach designed to intervene before a crisis situation. The goal is to prevent unnecessary jail, emergency department and hospital use by having different levels of care for individuals to step into. The city has a standalone crisis response center that can provide urgent care, short term stays, observation, substance abuse care and peer-run post-crisis care, according to Margie Balfour, who heads clinical innovation efforts for Connections Health Solutions, the company that runs the facilities in Arizona. It doesn’t turn people away for behavior or substance abuse issues or inability to pay, helping to build trust between the health system and law enforcement, Balfour said.

For Root's family there's a feeling that, even with the gaps in Boston's mental health care system, tragedy could've been avoided if only the police response wasn't so brutal and disproportionate. Boston in fact has its own co-responder program, the Boston Emergency Services Team, or BEST, that has been responding to individuals in mental health crisis alongside police since 2011 on calls related to everything from homelessness concerns to high-tension hostage situations. 

Root could have been a perfect test case for the approach, but the BEST team wasn’t engaged the morning he showed up at the medical center. It wouldn’t have been easy for a responding officer to figure out that he had been flagged in BEST’s database, said Melissa Morabito, an associate professor at UMass Lowell’s School of Criminology and Justice Studies, who’s studied the model. Representatives for the BEST program, which is contracted with Boston Medical Center, could not be reached for comment.

While there is nothing that stops BEST responders from intervening when weapons might be present, officers are sometimes wary to involve them in potentially dangerous situations, she added. In early 2020, there were between four and five co-responder clinicians on staff, funded by grant money, meaning that the chances for a clinician to be called to the scene were limited. The city’s 2021 budget allocates $2 million in city funds to the team, which will allow the Boston Police Department to hire 15 more responders

Such an investment does little for Root’s family. They are suing the police department and officers involved in Root’s shooting for excessive use of force and asking for an independent investigation. A trove of video, interviews and other evidence related to the matter — and obtained by the Root family through public records requests — offers a detailed picture of what happened on Feb. 7.

Fatal Encounter

David Godin was the first police officer to encounter Root after the security guard outside the hospital last year, according to an interview Godin gave investigators. Godin ran toward Root, and Root turned his back to the officer while yelling “I’m law enforcement, I’m law enforcement.” When Root turned around to face Godin, Godin had drawn his gun and had closed the space between them. Root was shot almost exactly as he drew his own paintball gun, in a sequence so chaotic that Godin fell back onto the wet pavement after firing.

The approach meant there was little time for Godin or Michael St. Peter, the second officer on the scene, to talk to Root or assess his state of mind. When dealing with any crisis situation, officers are supposed to slow down encounters and buy time, a deescalating tactic, said Seth Stoughton, an associate professor at the University of South Carolina School of Law who focuses on police policy. Moving into a person’s space abruptly is a tactical error and only serves to escalate situations, he added.

‘All the Systems Failed’: Inside America’s Mental Health Crisis

From the moment the officers saw Root to the moment they were shooting him, barely a minute passed. One of the bullets struck a bystander in the head, wounding his brain and eye. St. Peter told investigators that he believed he mortally wounded Root with his shots, but Root was able to get up, limp back to his car and drive off. Eventually he crashed and emerged from his vehicle, unresponsive and kneeling on the ground. Six officers arrived, one yelled “gun,” and they all began shooting.  

Evidence collected by Norfolk County and the Boston Police Department showed that Godin was not using his department-issued weapon, officers involved either weren’t wearing their body cameras or did not turn them on until the encounter had ended, and a decision to ram Root’s vehicle during the pursuit were all in violation of department policy. Root’s father, Evan Root, said that on the day of the shooting officers arrived at his home to deliver news of his son’s death, falsely adding that Root had shot someone — an error the department has yet to correct. 

Still, the Norfolk County district attorney’s office reviewed the incident and found that “the use of force by police in Brookline was objectively reasonable and justified,” according to a report from March 2020. The Boston Police Department is still conducting an internal affairs investigation and a firearms discharge review, one year later. Boston Police did not respond to a detailed request for comment on the case, citing their ongoing investigation, though they acknowledged the officers involved are still working. An attorney representing Godin referred Bloomberg CityLab to the city, which declined to comment. 

In the meantime, Root Bannon and her father are still searching for accountability. Last month they held a vigil for Root on the one-year anniversary of his death, demanding justice. The family’s petition to reopen the case and hold an independent investigation has gathered more than 12,000 signatures. The family delivered those signatures to state Attorney General Maura Healey on Feb. 26, whose office acknowledged receipt but has not yet responded, said Root Bannon. They hope their scrutiny will provide a shot at justice and closure.

“The system is set up where police are policing themselves. There’s no accountability or repercussions,” said Root Bannon. “You can’t really grieve because you’re like, I have to get to the truth.”

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