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What are contemporary methods of law enforcement response to those in mental health crisis.
Law Enforcement response to incidents involving persons in mental crisis is a topic of much discussion and controversy amongst the law enforcement community, and ordinary citizens. Traditionally, law enforcement training is geared towards responding to crimes in progress, and criminal investigations. Law Enforcement Officers who are not trained to properly deal with those in mental crisis are less likely to deescalate the situation and are more likely to use force (Khalsa et al., 2018). Once contact is made with the person in crisis they can end up arrested and placed in jail, even though other programs and options may be more appropriate for them.
This is of no fault to Law Enforcement Officers in areas where they receive no, or minimal training on the issue, and have little to no connections with resources in the community for mental health related issues. In contemporary times, Law Enforcement Officers are more commonly seen as generalists, and are expected to handle a wider variety of issues during their shift, including civil issues, traffic issues, mental health issues, and more. Since the traditional focus and training of most law enforcement officers is based upon response to crimes in progress and criminal investigations, what is a better contemporary model to help law enforcement respond to incidents involving subjects experiencing a mental health crisis?
A model and method for law enforcement to respond to incidents involving those in mental health crisis is the Crisis Intervention Team (CIT) model (Kubiak et al., 2017). The acronym CIT is sometimes also used to refer to Crisis Intervention Training. The CIT model is a collaborative effort of law enforcement, social services, and those in the community to have better interactions with those suffering from mental illness (Kubiak et al., 2017). A Crisis Intervention Team is often comprised of local law enforcement, county health services, mental health organizations, and those in need of mental health services (CA POST, n.d.). The CIT model is not simply training for Officers, it is a revamp of the system which allows CIT Officers to work side by side and integrate with the local mental health network (Fisher & Grudzinskas, 2010).
The crisis intervention team model was first developed in the late 1980’s in Memphis, Tennessee after an Officer shot and killed a man who was suffering from a schizophrenic episode, armed himself with a knife, and threatened to kill himself (Watson et al., 2017). This incident generated much public dismay, which led the mayor of Memphis to organize a collaborative task force of law enforcement, mental health services, mental health advocacy groups, and higher education (Watson et al., 2017). This was a perfect example of how untrained Officers are not properly equipped to deal with potentially hostile and volatile persons suffering from serious mental crisis episodes. The team created in Memphis became the groundwork for CIT, and is commonly referred to as the Memphis Model (Watson et al., 2017). Since the Memphis model was created, very similar models have been adopted by many agencies nationwide (CA POST, n.d.).
Deinstitutionalization of persons with serious mental illness began several decades ago, thus moving them into society and into contact with local law enforcement (Kubiak et al., 2017). The resulting lack of treatment programs and dedicated housing for those with mental illness has led to increased contact with law enforcement and a need for law enforcement to help with the situation (CA POST, n.d.). Law Enforcement Officers were not originally intended to be the entity tasked to deal with those in need of mental health help, however when those suffering from a mental health condition commit crimes, they are often encountered by Law Enforcement. Society relies upon law enforcement to deal with many mental health related incidents and crisis response because law enforcement is equipped with safety equipment, and is usually in service 24 hours a day, seven days a week.
Law enforcement mental health related calls for service often take long periods of time to resolve, are highly volatile, involve the same individual(s) repeatedly, involve minor criminal offenses, require the need for community mental health resources, and require specialized training and skill sets for officers to be successful (CA POST, n.d.). This is where the CIT model can be of great help to the agency, and the community. Some goals of CIT programs are to reduce injuries to responding Officers and persons in mental health crisis during these incidents, and to divert those suffering from mental health crisis away from the criminal justice system and towards other programs and resources that are better suited to treat their conditions, and minimize future negative law enforcement contact (CA POST, n.d.). After adopting the CIT model in Memphis, they saw the arrest rate for incidents relating to subjects with serious mental illness drop to around two percent, while the arrest rate for similar incidents in areas without CIT was sometimes higher than 20 percent (Fisher & Grudzinskas, 2010).
The prison system, along with law enforcement agencies nationwide, are bearing a large part of the burden of our nations growing mental health problem. It is argued by some experts in the field that our nation has shifted from treating and caring for individuals suffering from mental illness to policing and incarcerating them (Segal, 2014). The US Bureau of Justice reported that over half of the nations inmates reported having a mental health problem that is indicative of mental illness (Segal, 2014). Many mentally ill inmates are often unable to receive certain types of therapy and medications that they may need to stabilize themselves (Segal, 2014). It was estimated recently that at least one million people with mental illness are booked into our jails every year, and people with mental illness are incarcerated at a rate 1.5 times that of the rate at which they are treated in psychiatric facilities (Fisher & Grudzinskas, 2010).
Mental health advocates argue that the criminal justice system is not properly equipped to deal with people suffering from serious mental illnesses (schizophrenia, bi-polar, severe depression) (Segal, 2014). Serious mental illnesses defined as are those which seriously impair ones ability to perform one or more major life activities (Campbell, 2019). As of 2018, roughy 11.4 million people were reported to suffer from serious mental illnesses (Campbell, 2019). It has also been argued that placing mentally ill individuals who committed relatively minor offenses (or no offense at all) in contact with law enforcement, and the criminal justice system, brings danger to the responding officers and to the person in crisis (Segal, 2014). The responding Officers may not have been trained how to recognize and deal with someone who exhibits these mental crisis symptoms, and the person in crisis may not comprehend the gravity of what they are doing and what Officers are asking them to do.
The CIT model generally involves 40 hours of training to Officers to be able to better recognize mental illness, deescalation techniques, and connecting people in crisis with mental health services (Watson et al., 2017). Sometimes Officers in CIT programs will get even more advanced training. Communication skills are key for these Officers and others involved with the program. Active listening, displaying empathy, and genuineness are some communication skills sought by a CIT program (Chopko, 2011). Officers who received this CIT training reportedly view subjects with mental illness more as having a brain disorder than begin an offender, and they were more likely to use verbal deescalation techniques to avoid confrontations (Chopko, 2011).
Officers who are part of a CIT program should ideally be there voluntarily and not forced onto a CIT (Watson et al., 2017). This is important because as with any specialized program, you need workers in the program who are dedicated an passionate about what they are doing. If you force Officers onto a crisis intervention team who are not passionate about working towards better mental health resources for citizens, they likely will not exert the effort needed for success. A study by Compton et al (2017) found that Officers who volunteer to join a CIT program are more likely to have been exposed to the mental health system in some way, and generally have better opinions and mindsets about those suffering from mental illness.
These trained Officers also show better deescalation skills, better referral decisions, and are more likely to refer someone to treatment services than to simply make an arrest (Compton et al., 2017). Some evidence suggests that Officers forego involvement with the mental health system because they do not view their role as being a mental health worker, however many Officers agree that lower level mentally ill offenders would be better served in the mental heath system than in jail (Fisher & Grudzinskas, 2010). With that being said, I believe it is important to train as many Officers as possible with CIT methods. The reality is that crisis intervention teams may not always be available on duty, or they may not be the first to arrive at the scene of a crisis, so most Officers should receive the training in order to have safer crisis responses.
To better understand how the current mental health situation came to be, we must look back at societal changes in the last several decades. Earlier in the 20th century, people suffering from serious mental illnesses were confined to mental hospitals, where they were removed from society and provided some level of treatment (Okada et al., 2018). The discovery of certain drugs in the 1950’s, along with a growing population, less available beds, and shifting public opinion regarding the federal government paying to house and care for the mentally ill, led to many of these institutions closing down in the 1960’s an onward (Okada et al., 2018). The Lanterman-Petris-Short act in California (1969) made it much more difficult to detain someone on an involuntary mental health hold, and after this act passed, other States soon follow with similar laws (Okada et al., 2018).
The higher threshold of the circumstances needed to involuntarily detain someone for a mental health evaluation resulted in less mentally ill patients receiving the long term care they need. Because of these changes, the current standard procedures for dealing with those in mental crisis is to admit them into an in-patient hospital setting to be stabilized temporarily, and once they are stabilized, they are released without guarantee of further treatment or follow up (Okada et al., 2018). For example, in 1960 there were roughly 314 open hospital beds per 100,000 people in the nation, whereas in 2005 there were roughly 17 open hospital beds per 100,000 people (Okada et al., 2018). This is a major reason why we are seeing a revolving door of mentally ill patients. If there is no way to keep them in treatment for long term, and they are released without follow up, they are likely to return to the mental health system.
Some believe this deinstitutionalization has directly led to the increase of mentally ill offenders in the criminal justice system because they have dispersed into community’s, many of which are homeless, and many communities do not have the resources to deal with them appropriately (Okada et al., 2018). This results in law enforcement having more frequent contacts with these subjects. While persons suffering from serious mental illness do commit serious violent crimes from time to time, many of these persons commit low level offenses and deviant behavior. Law Enforcement may be the most appropriate entity to respond to violent crimes for public safety purposes, but other entities such as psychiatric technicians, homeless outreach, and mental health advocates can assist law enforcement during their contacts with these mentally ill offenders to deescalate and divert the situation to a better resource.
A somewhat recent study was conducted in Colorado regarding the influence of crisis intervention teams during the first 10 years they were implemented in Colorado law enforcement agencies. During the course of the 10 years, over 95 percent of the contacts with law enforcement crisis intervention teams did not result in arrest, most resulted in transports for services or mental health evaluations (Khalsa et al., 2018). Some factors however did lead to a higher likelihood of going to jail instead of treatment, such as presence of a weapon, level of violence used or threatened, and level of substance abuse (Khalsa et al., 2018). This study showed how successful the CIT program in Colorado is at diverting many subjects with serious mental illness into treatment and services. Other study’s have been done on this subject which also conclude that CIT programs reduce police use of force, arrests, and increase referrals to treatment centers for those with mental illness (McGriff et al., 2010).
It has also been noted that CIT trained Officers are more inclined to feel better prepared to handle interactions with the mentally ill as opposed to non CIT trained Officers (McGriff et al., 2010). In a study of CIT trained Officers operating in a large airport, Officers perceived that their specialized training gave them a significantly better understanding of recognizing psychiatric symptoms and allowed them to adjust their response based on the symptoms recognized (McGriff et al., 2010). This specialized and educated response allowed the Officers to feel as though they could adjust their methods of interaction with subjects to better understand the root cause of what was happening with someone experiencing a mental illness crisis (McGriff et al., 2010). This led to a feeling among the Officers that they could deescalate the individuals more effectively (McGriff et al., 2010).
A major factor with any mental crisis related incident response is deescalation by law enforcement and first responders. Deescalation techniques show that Officers do not want to use force if they don’t need to for protection, and by using deescalation techniques they can bring a peaceful resolution to the crisis. Officers have reported that calls involving someone in mental crisis are some of the scariest to respond to because they are highly unpredictable and they do not know if the subject will be violent or not upon arrival (Chopko, 2011). It has been stated that many law enforcement officers often spend more time during their shifts dealing with persons with mental illness than they do investigating burglaries, assaults, and traffic accidents (Fisher & Grudzinskas, 2010). This amount of time spent contacting persons suffering from mental crisis shows that it is not a subject matter to be taken lightly.
Our countries mental health problem should not be equated to a temporary uptick in retail theft, a rise in auto theft, or even a spike in vandalisms. This is a matter, which if not taken seriously, may result in a worsening societal problem, and injuries/deaths to those in crisis and the responding professionals. Many law enforcement agencies have specialty units such as burglary task force’s, gang task force’s, and retail theft investigation units. Would it not be prudent for agencies to dedicate the time and resources to a crisis intervention team that could potentially divert psychiatric patients towards treatment resources, lower their population in jails, and reduce law enforcement injuries and use of force?
Research has suggested that the most competent law enforcement officers possess the best deescalation skills, are calmer in volatile situations, and use the minimum amount of force necessary to resolve the situation (Chopko, 2011). Crisis intervention can be defined several different ways. One definition of crisis intervention is that it is the short term process of reestablishing a persons equilibrium in order to solve a problem (McMains & Lanceley, 2003). Looking at crisis intervention through this definition, we can see that a problem can be solved in the short term by using various methods.
Physical force is one option to end the situation, and verbal deescalation to gain compliance is another option. I argue that while physical force may be a necessary option sometimes for self defense, or in defense of others, physical force does nothing to remove the subject from a psychiatric episode. If responding Officers can verbally deescalate the situation and restore the subject to a state of equilibrium, even if only temporarily, they have solved that problem. Crisis intervention can restore the person to their pre-crisis level of problem solving, diffuse intense emotions that are interfering with the persons ability to problem solve, and it is limited by time and limited to the current problem (McMains & Lanceley, 2003). McMains and Lanceley (2003) argue that trained police hostage negotiators can use crisis intervention techniques to diffuse situations more effectively and efficiently.
In 2018 there were 992 persons killed by law enforcement nationwide, 208 of them were in mental health crisis when they were killed (Campbell, 2019). As of recently, over two thousand police departments, and over 25 percent of County law enforcement (Sheriff/County Police) have implemented CIT programs, with the Memphis model being most prevalent (Campbell, 2019). While this is a great start, the statistics above show that many subjects are still involved with violent police encounters resulting in their death. While some of these encounters may never be able to be diffused verbally, even by the most skilled CIT Officers, some of them could likely have been deescalated with the right CIT trained personnel on scene.
Many persons with serious mental illness qualify as being disabled under the Americans with Disabilities Act (ADA), if their mental illness impacts one or more of their major life activities (Campbell, 2019). This is yet another reason why the traditional law enforcement response to those in a state of mental crisis is inadequate, and CIT training should be adopted for Officers, as it is a safer and more compassionate way to interact with those in mental crisis, many of which qualify as being disabled. Since law enforcement are government agencies, they are required under ADA to make reasonable modifications to their policies and procedures to accommodate disabled persons (Campbell, 2019).
Given the nature of this verbiage and the law, law enforcement may find themselves prone to a lawsuit for violating ADA if they have not provided training for officers and accommodations for those with serious mental illness who qualify under the ADA. In 2012, the US Department of Justice required the Portland Police Bureau to adopt CIT training for their Officers due to alleged excessive force used against persons with mental illness (Campbell, 2019). Also as part of consent decrees, Cleveland and Seattle have been directed by the DOJ to implement CIT training (Compton et al., 2017).
Although CIT training is not mandatory nationwide at this time, agencies are adopting the training to improve service. If the courts a lawmakers were to modify ADA to require CIT type training for all law enforcement officers nationwide, those suffering from serious mental illness may be dealt with more safely and appropriately for their condition (Campbell, 2019). A study conducted in Michigan showed that after CIT implementation, law enforcement was significantly more likely to utilize crisis centers as an option for someone experiencing mental crisis (Kubiak et al., 2017). It is believed that it is important for a crisis center (or hospital) have a no refusal policy for these types of situations, and it’s also important that law enforcement and their local mental health providers be on the same page as to what their policies and procedures are (Kubiak et al., 2017).
In the Michigan study, prior to CIT implementation, Officers felt as though the crisis centers were not on the same page as them, and psychiatric units would not provide proper care, which left them feeling as though jail was the only option (Kubiak et al., 2017). It is clear that all stakeholders must communicate and be like minded as to what services they can provide, and how they will deal with the subjects who are brought under their care, both in the short term and long term. CIT teams and training should incorporate not just law enforcement, but medical workers, advocates, and psychiatric workers. Essentially all of those who are going to be involved in the process of bringing someone into the mental health system for treatment and observation. The Michigan study Officers also reported that before CIT training they often took crimes at their face value and did not dig deeper to see if there was an underlying mental health issue that led to the call for service or crime being committed (Kubiak et al., 2017). After CIT training these Officers reported that they felt better equipped to diagnose the cause of the problem and they were more prone to slow down and take their time diffusing the situation (Kubiak et al., 2017).
This shows that CIT training is not only beneficial for mental health related incidents, but for more non-mental health related calls for service as well. For example, if an Officer can take the time to slow down, listen to an upset resident during a neighbor dispute, they may have diffused the situation enough to prevent further incidents or an escalation of the dispute. Traditional law enforcement focuses on criminal investigation, and in many busy areas, this can leave residents who have smaller issues such as civil disputes or minor mental health issues feeling left out and underserved. If CIT trained Officers can have more quality contacts with the public, and leave the public feeling better served, than it is a win for everyone. The Presidents task force on 21st century policing even recommended in 2015 that all recruit and in service Officers go through crisis intervention training (Compton et al., 2017).
Since CIT training is not mandatory nationwide at this time, even if an agency does not have a full CIT implementation, there should be some CIT trained Officers available on a shift (Compton et al., 2017). This will ensure that at least the most severe crisis responses have a chance of intervention by CIT trained Officers. Even if all (or most) of a departments Officers are trained in CIT, this should not forego the need for a true crisis intervention team (Memphis model), if the agencies resources allow for it. Officers are expected to wear many hats during a patrol shift. In busy metropolitan areas, an Officer also may have numerous calls for service pending while they deal with any one incident. To obtain the best quality of CIT response a team of dedicated Officers can strictly direct their focus on mental health crisis incidents. As previously stated, law enforcement agencies dedicate teams of Officers for issues such as burglary, auto theft, and more. So why not dedicate a team of Officers for high stake incidents involving mental health crisis?
With up to 10 percent of law enforcement contacts involving someone with serious mental illness, and roughly 1 in 4 fatal law enforcement shootings involving someone with serious mental illness, more can be done to better prepare law enforcement and their community mental health system to encounter these situations (Watson et al., 2017). While much research is still needed on CIT as an evidence based practice in policing, researchers are confident that CIT can be designated as an evidence based practice for improving Officers attitudes and thought processes about mental illness (Watson et al., 2017). CIT should not be considered as an afterthought once high profile negative encounters with persons with mental illness have occurred. By this time damage has already been done to the agencies reputation, and trust has been lost by those with mental illness and their family members. Crisis intervention teams, and training, provide a resource that is needed to bring law enforcement to the level of professionalism that is expected by their communities in contemporary times.
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