Police Intervention with the Mentally Ill, Part 2: CIT & Diversion Program Opportunities
This is Part 2 of a series on improving law enforcement interactions and outcomes with the mentally ill. Part 1, “Successful Social Worker Partnerships,” in our Sept/Oct 18 issue, covered options for collaborating with social workers for mental health-related calls. Part 2 examines the possibilities for successful outcomes that lay within diversion programs.
Law enforcement agencies continue to seek better programs and tools for successful interactions with — and outcomes for — the severely mentally ill, in order to ensure the safety of officers and civilians, to reduce strains on police resources, and to help divert the mentally ill away from the criminal justice system and toward medical treatment.
Barriers to Care & the Criminal Justice Cycle
While only 4% of the US adult population struggle with a severe mental health illness1 — more than 25% of all fatal law enforcement interactions involve a portion of this small group. (Maciag) When medicated, those suffering from these serious illnesses are no more violent than the general population; however, when not treated, these individuals can become more violent than the population, a violence that only increases when drugs or alcohol are added to the mix.2 (MIPO)
Due primarily to poor access to mental health care, federal and state prisons and local jails have become treatment centers for those whose serious mental illnesses have resulted in violent or illegal behavior. “Jails are the largest mental health facilities in the US. The cost of incarcerating mentally ill citizens is three to five times what community health treatment would cost. . . . The total cost of mental illness being handled by our emergency rooms and jails each year is around $45 billion.” (Ramsey)
Mental Health America’s (MHA) “2017 State of Mental Health in America: Access to Care Data” reports that the most common barriers to treatment include: (MHA)
- no insurance or inadequate insurance,
- shortage of available in-network treatment providers,
- lack of — or wait lists for — appropriate treatment (e.g., inpatient treatment, intensive community services), and
- inability to pay such costs as copays, uncovered treatment, or providers who don’t take insurance.
In fact, according to the National Alliance for Mental Illness (NAMI), 60% of the US population who suffer from any mental illness did not receive health care services in the past 12 months; and, 17% were uninsured. (MHA) Even among those with health care insurance, coverage restrictions and limited in-plan mental health providers precluded 56.5% of adults with a mental illness from receiving treatment.(MHA)
For the incarcerated, treatment is free, available, and utilized by the population. A DOJ report reveals that 44% of jail inmates and 37% of state or federal prison inmates have been diagnosed at some point in the past with such conditions as schizophrenia, bipolar disorder, PTSD, major depression, or severe anxiety disorders.(Bronson) In both jail and prison groups, about 37% were receiving some type of treatment while incarcerated, and 30% of both inmate populations were taking prescription medication.3
Once released from jail or prison, without easy access to continued care, those with mental illnesses commonly relapse and end up back in prison. As MHA states, “Reliance on the criminal justice system to provide treatment . . . is almost certainly counter-productive. Adding the stigma of criminal charges and conviction makes it even harder for persons burdened with the substantial stigma of mental illness to find or maintain meaningful employment, find decent housing, and pursue meaningful recovery.” These issues are significant not only for former inmates but for their families, communities, and law enforcement.
CIT Diversion Programs
Crisis Intervention Teams (CIT) are considered pre-booking diversion programs that are meant to “increase safety in encounters and when appropriate, divert persons with mental illnesses from the criminal justice system to mental health treatment,” as stated by Amy Watson, PhD, and Anjali J. Fulambarker, MSW, in their research report for the National Institutes of Health.
The CIT concept was conceived 30 years ago, following the fatal shooting of a mentally ill substance abuser by a Memphis, TN, police officer. The ensuing work of the Memphis community task force — law enforcement professionals, mental health and addiction professionals, and mental health advocates — resulted in the Memphis CIT Model. (Watson) After three decades of international success, NAMI, the US Departments of Justice and of Health and Human Services, the White House Conference on Mental Health, and others, have named the Memphis CIT Model as a best practice. (Dupont) Although their numbers are rising, fewer than 3,000 US agencies have CITs. According to the University of Memphis, each state in the US presently has at least one local, county, or regional CIT program, with the exceptions of West Virginia, Rhode Island, Arkansas, Alabama, and the District of Columbia. (CIT Center)
Among the measurable advantages of CITs: (Dupont)
- reduced injuries and use of force at mental health-related calls;
- lower arrest rates;
- increased mental health referrals; and,
- faster mental health-related response rates.
According to Randolph Dupont, PhD, of the Department of Criminology and Criminal Justice at the University of Memphis, other advantages of the CIT approach include a positive change in “attitudes/perception” and in the “nature of intervention,” as well as “clarifie[d] lines of responsibility.”
Watson’s research shows that CIT programs also are associated with an increase in voluntary transport to hospitals. A 2008 study, published in Psychiatric Services and cited by Watson, found that CIT officers used force in only 15% of interactions deemed “high violence risk.” Within that 15%, the force was “low-lethal.” Watson revealed that “CIT officers used less force as subject resistance increased than officers that were not CIT trained. . . . [O]fficers reported that application of their CIT skills reduces the risk of injury to officers and persons with mental illness.”
The development of the Memphis model was not without difficulties arising among its stakeholders. Some CIT stakeholders still struggle with the same trust issues that the Memphis task force faced. According to Watson, while structuring the program “it became abundantly clear that law enforcement and mental health providers . . . did not trust each other. Providers felt that police officers lacked understanding of mental illness and would often exacerbate crisis situations. Police officers were frustrated that hospitals often would not provide care for people that they transported who were clearly symptomatic.” By continuing to work together, each obtained an understanding of the other, which helped lead to the model’s success.
At the core of a CIT program are 40 hours of specialized training for officers who have volunteered and are then selected to become CIT officers. According to Watson’s NIH report the imperative is not how many CIT-trained officers an agency staffs; instead, the key is to train the right officers for the program. Some people have a “particular disposition and interest in handling mental health calls. This better prepares them to use CIT training to become effective,” stated Watson.
CIT training is provided by clinical social workers or other mental health clinicians, law enforcement trainers, and advocates in classroom and experiential settings.(Watson) For example, the Illinois Law Enforcement Training and Standards Board has offered state-certified CIT training since 2003 and instructs on topics common to all CIT training: (ILETSB)
- mental illness signs and symptoms,
- risk assessment and crisis intervention skills,
- verbal de-escalation and tactical response,
- child, adolescent and geriatric issues,
- returning veterans and PTSD,
- autism and cognitive/developmental disabilities,
- co-occurring disorders (substance abuse),
- medical conditions and psychotropic medications,
- law enforcement response and legal issues, and
- community resources.
CIT training may also feature panel discussions with clinicians, family, and mentally ill people. Once trained, CIT officers perform regular patrol duties but are always available for immediate dispatch to a mental health call. (Watson)
Only one discoverable study is available on the results of CIT beyond the initial encounter. That 2004 study in Behavior Science & the Law found “diversion from arrest by pre-booking programs, such as CIT, increased mental health service utilization in the subsequent 12 months for persons with serious mental illnesses.” (Broner)
Court-Ordered Diversion Programs
While law enforcement officers are directly involved in the implementation of CIT programs, such diversionary programs as Mental Health Courts (MHC) and Assisted Outpatient Treatment (AOT) are managed in the criminal and civil courts, respectively. However, all officers and agencies benefit from understanding how these programs work and their records of success — and from advocating both for their use in their jurisdictions or regions and for individuals who may benefit. In October 2014, the IACP endorsed AOT programs, following the National Sheriffs’ Association endorsement. (TAC)
Mental Health Courts
The purpose of a MHC is to direct the severely mentally ill toward community-based treatment by “targeting frequent users of local jails and prisons. [MHCs] are voluntary and use therapeutic jurisprudence to encourage treatment engagement.” (Munetz) “If a prosecutor or DA believes a person who has been charged with a low-level crime has a mental illness, they may divert him or her to a mental health court,” explains DJ Jaffe, author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. “The mental health court will say, if you accept treatment for X amount of time, we will drop your charges, and the person comes back every week to see if he’s still complying. Basically, you have somebody who has committed a crime — often because the mental health system didn’t treat them — deferred to a court, which then tells the mental health system to treat them.” (Rodriguez)
An example can be found in Alleghany County, PA. In a study conducted by the RAND Corporation, the Allegheny MHC was “a success in achieving its mission to divert nonviolent offenders with serious mental illnesses out of the penal system and into community-based health treatment and other services.” The program “did not result in substantial incremental costs.” Treatment costs were offset by a decrease in inmate costs. (Psychiatric Times) RAND reported that the county’s MHC team meets to review each case — including circumstances, diagnosis, and need for treatment and supervision — before making an offer to the offender. The team is comprised of the MHC judge, assistant district attorney, public defender, program monitor, MHC forensics specialist, and probation liaison. An offer includes help obtaining treatment, housing, and public assistance in return for regular compliance hearings. (Psychiatric Times) Jaffe says, “It’s a long, unnecessary round trip. The mental health system should just treat them.” (Rodriguez)
Program eligibility, length, and components may vary but many include program components similar to those of Cobb County, GA (see Figure 2). Program graduations are common celebrations. And there is much to celebrate: (McNiel)
- MHC graduates benefit from improved mental health;
- They are 26% less likely to be charged with any new crimes as late as 18 months out of the program, compared to those not in a MHC; and,
- MHC graduates are 55% less likely to be charged with a new violent crime, compared to those not in a program.
Assisted Outpatient Treatment
AOT is a promising diversion tool administered through civil courts for those who are frequently hospitalized and respond well to treatment but discontinue treatment when released, relapse, and then become a danger to themselves or others.(Munetz) Depending on their jurisdictions, officers may be evaluators for AOT candidates. Other law enforcement AOT stakeholders include CIT officers, chiefs, and jail liaisons to mental health centers. (Esposito)
One common myth is that AOT involves in-hospital treatment. However, the truth is the opposite: AOTs are designed to help the mentally ill function outside of the hospital.(TAC) As Jaffe explains, “Basically, [it is] the same thing as MHC, except it happens before the crime is committed, after the person already has a history of multiple instances of homelessness, arrest, incarceration, or hospitalization due to being off medication. . . [T]he court, with all due-process, can order the person to . . . mandated and monitored treatment while he or she continues to live in the community. It doesn’t involve locking someone up or in-patient commitment—it’s less expensive, less restrictive.” (Rodriguez)
AOTs nationwide report significant, quantifiable success rates. The Treatment Advocacy Center (TAC) cites a study that found when long-term AOT is combined with routine outpatient services4, the number of hospital admissions is reduced by 57% and length of hospital stays decrease by 20 days, compared to individuals not in an AOT program. For individuals with schizophrenia and other psychotic disorders, long-term AOT resulted in 72% less hospital admissions and an average 28-day reduction in length of hospital stay compared to those not in an AOT. (TAC)
The TAC also cites results with the following success rates among those who have participated in New York’s AOT program5: