Position Statement 59: Responding to Behavioral Health Crises

Policy

People with serious and untreated mental health and substance use conditions often encounter barriers that prevent receiving the right services. The absence of appropriate services causes many harms including mental health and substance use crises. Unfortunately, we do not have appropriate systems in place to respond to mental health and substance use crises. Among the wide-spread problems are:

• the lack of alternatives to calling 911;
• the lack of training for 911 personnel;
• the lack of alternatives to dispatching law enforcement personnel in response to mental health and substance use crises:
• the lack of training for law enforcement personnel; and
• the lack of crisis and respite services with the expertise to manage mental health and substance use conditions in a manner that facilitates recovery and reduces hospitalization, involvement in the criminal justice system and homelessness.

As a result, persons experiencing mental health or substance use crisis may:

• end up in confrontations with law enforcement personnel which have tragic outcomes;
• be transported to emergency rooms and be admitted or committed to inpatient psychiatric facilities when these outcomes are unnecessary and may be harmful to the person; and
• be transported to a jail and subjected to ongoing involvement in the criminal justice system when these outcomes are unnecessary, are harmful to the person and do not lead to increased public safety.

Mental Health America (MHA) supports coordinated efforts to:

• identify and provide those services necessary to reduce the occurrence of mental health and substance use crises;
• ensure that crises are dealt with in a manner that is least damaging to individuals and most conducive to a peaceful and therapeutic outcome;
• improve training for law enforcement and other first responders to persons in crisis; and
• provide mobile crisis response teams with linkage to crisis respite or psychiatric urgent care centers.

For a full review of alternatives,, including cost-benefit analyses, see SAMHSA’s 2014 report: Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies.1

People with serious and untreated mental health and substance use conditions often encounter barriers that prevent receiving the right services. Police officers, behavioral health providers, and community stakeholders face challenges in determining and implementing the proper ways to intervene during behavioral health crisis. Unfortunately as a result, interactions with people with mental illness in crisis often result in actions that significantly hurt recovery. For example, in 2016, a quarter of all fatal police shooting nationwide involved people with behavioral health or substance use conditions.[1]

In addition to these tragic outcomes, services and funding are frequently misused. For example, police officers and emergency room personnel are caught up in a cycle of inappropriate, ineffective, and untimely referrals to render care that often results in increased fear and mistrust among individuals with mental health needs. Too often, individuals are also inadequately treated in emergency departments or inappropriately sent to jails due to the lack of more suitable options.

Mental Health America (MHA) supports coordinated efforts: (1) to identify and provide those services necessary to reduce the prevalence of mental health and substance use crises; and (2) to ensure that crises are responded to in a manner that is least damaging and most apt to result in a peaceful and therapeutic outcome. This includes providing mobile crisis response teams made up of mental health professionals and peers and linking to peer-run crisis respite or psychiatric urgent care centers. For a full review, including cost-benefit analyses, see SAMHSA’s 2014 report: Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies.[2]

Background

Increasing Police Contacts

In the twentieth and twenty-first centuries, police contact with people in behavioral health crises has increased. Prior to 1960, people with behavioral health conditions were removed from the community and confined in inpatient facilities, or people were arrested intermittently for being drunk and disorderly or disturbing the peace, detoxified or de-escalated in jail, and released with little ongoing treatment. Now, the criminal justice system is one of the primary institutions called upon to deal with the persons with mental health concerns, and while people with substance use conditions may not be jailed for having an addiction, they are often arrested for acts committed while using. In the case of substances like amphetamines, crack cocaine and PCP, intervention often incites resistance and does not effectively support recovery.

Law enforcement agencies spend a significant portion of their resources engaging with people experiencing behavioral health and substance use conditions. Approximately 10% of all police contacts involve persons with serious mental illness.[3] Although intoxication is harder to quantify, the number of police contacts with people disabled by substance use is undoubtedly greater. However, few attempts to quantify the resources spent on these interventions have been made to date.[4] Mental health issues are more commonly addressed, but similar strategies need to be developed and used in dealing with substance use disorders.

Police arrest a substantial number of people with behavioral health conditions. The percentage of those in pre-trial detention with serious mental illnesses in the United States is 14.5% for males and 31% for females.[5] However law enforcement officers often express reservations regarding the lack of training and resources devoted to the engagement and treatment of people with mental illness and addictive disorders. As of 1999, a majority of U.S. police departments in cities with populations over 100,000 did not have any specialized strategies to deal with behavioral health crises.

Alternative Response Models

Many of the problems associated with police involvement in behavioral health crises can be avoided by creating alternatives. Non-behavioral medical emergencies, such as heart attacks, strokes and non-vehicular accidents are often handled by the 911 system. But rather than dispatching a police officer, an ambulance is sent. A law enforcement response to a mental health crisis is almost always stigmatizing for people with mental illnesses and should be avoided when possible. Whenever possible, mental health crises should be treated using medical personnel or, even better, specialized mental health personnel. Substance use disorders need to be handled in a way that promotes recovery, not victimization.

While SAMHSA’s 2014 report, Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, offers a comprehensive list, some models that MHA would highlight include:[6]

Mobile Crisis Response Teams

Mobile Crisis Response Teams should be the first point of contact in calls regarding mental health crises. Made up of mental health professionals, community health workers, and/or peers, these teams have the knowledge and skills to respond and refer individuals in crisis to the appropriate resources. They work closely with police, crisis services, and communities to support individuals and their families in navigating systems and supports. With specialized knowledge and the ability to engage people who may be at risk for “wellness checks,” access to Mobile Crisis Response Teams can help prevent crises and avoid unnecessary hospitalization, police interactions, and arrests. The best of these models contain peers who can most effectively empathize with and engage the individual in crisis.

Peer-Run Crisis Respite

When responding to mental health crises, emergency responders often take people in crisis to emergency rooms that are ill-prepared to support them. To promote the best outcomes for recovery, crisis respite should be made available to all. In contrast to the unnecessary hospitalization and missed opportunities for connecting to services that occur in emergency rooms, crisis respite services are tailored specifically to the need of consumers experiencing crises. Peer-run crisis programs are places where people can to connect with peers with lived experience of mental health conditions, in an environment that promotes autonomy and empathy and provides people with the hope and resources to move in their recovery. This includes linking people in recovery to ongoing community-based services.

Psychiatric Urgent Care Clinics

Psychiatric urgent care clinics are the same as other urgent care clinics, but are specially trained to attend to mental health and substance use needs. It offers a place for individuals to go and receive immediate attention, avoiding a potential crisis. By making pre-crisis services available like any other health care services it makes mental health crisis avoidance accessible and normative.

Police Specialized Response

Crisis Intervention Teams

While Crisis Intervention Teams, or CIT, focus on law enforcement training and procedures, the program is also designed to coordinate the efforts of law enforcement personnel, mental health providers and community stakeholders in order to increase the safety of encounters and, when possible, divert people suffering from mental illness away from the criminal justice system and into mental health treatment. The fundamental element of the CIT model is 40 hours of specialized training provided by mental health clinicians, consumer and family advocates, and police trainers.[7] The curriculum includes training on recognizing the signs and symptoms of mental illnesses in addition to training on mental health treatment, co-occurring disorders, legal issues, and de-escalation techniques.

CIT identifies eight elements that serve as core components of the program:

• partnerships between law enforcement and mental health advocacy;
• community ownership through dedicated planning, implementing, and networking;
• law enforcement policies and procedures;
• recognitions and honors of CIT officers' accomplishments;
• availability of mental health facilities;
• basic and advanced training for officers and dispatchers;
• evaluation and research; and
• outreach to other communities.[8]

Co-Responder Model

In the co-responder model, trained police officers work together with behavioral health workers to respond to crisis calls and ensure that appropriate services and resources are provided. The goals of the co-responder model are deescalate the crisis, prevent injuries, provide appropriate services, and reduce the number of arrest.[9] The initial assessment is conducted with a trained behavioral health worker at the scene which can prevent unnecessary arrest or hospitalization.

The Benefits of Alternative Response Models

Alternative crisis response models offer an opportunity for law enforcement agencies, behavioral health providers, and community stakeholders to work together to provide the most appropriate intervention to those in crisis. Communities and law enforcement agencies that have implemented alternative crisis response models have seen positive results. Some promising initiatives include:

• Peer respites are now available in 11 states. Research on peer respite identified that guests are 70% less likely to use inpatient or emergency services, [10] hospital costs for respite users were one third the cost of non-users, [11] and respite users experienced greater improvement in symptoms, social activity, and functioning compared to users of inpatient services.[12]
• In Miami-Dade County, behavioral health crisis calls are directed to trained CIT police officers that have diverted over 9,000 calls to crisis units and responded to over 40,000 without arrest or hospitalization over the last 5 years of the program.[13]
• The City of Akron, Ohio, one of the first cities to implement the Memphis CIT Model, also developed a supplemental intervention program for at-risk populations. The Akron “CIT Outreach Program,” links law enforcement officers with outreach workers from “Community Supports Services.” The outreach team travels in a marked cruiser to contact referrals and attempts to engage people with behavioral health issues before a crisis arises. The team refers individuals to mental health and other services, such as elder care and drug addiction services. When the team transports an individual in a cruiser, the person normally rides without handcuffs next to a mental health case manager, in order to emphasize that the person is not under arrest. People are only restrained if the person is determined to be at risk of harming him or herself.
• A pilot program in Amsterdam, the Netherlands, seeks to use ambulances rather than patrol cars whenever possible for transportation in responding to mental health treatment needs.[14]
• A pilot program at the George Washington School of Medicine in 2013 sought to decrease the amount of inpatient psychiatric treatment by dispatching “mobile crisis units” staffed with a paramedic and a licensed social worker to co-respond to 911 calls triaged as mental health treatment calls.[15] The crisis unit focused on offering alternatives to inpatient treatment. It was able to “provide patients with same-day or next-day appointments, attempt to re-engage patients with their mental health providers, assist patients with psychiatric medication refill needs and referral follow-up options.”[16] The crisis unit also responded to situations in which an ambulance crew was contemplating physically or chemically restraining a person. The on-scene crew was directed to delay restraint until the crisis team arrived in order to first attempt verbal de-escalation before any restraint was used.

Training Dispatchers

Responding appropriately to behavioral health crises requires that those who answer “911" calls and coordinate and dispatch responders also be trained to recognized such crises and be knowledgeable about all of the alternatives available for responding to various kinds of crises.[17]

Avoiding the Use of Handcuffs and Restraints

Being taken away from one’s home, a community treatment setting or other location in handcuffs is a particularly traumatizing and a sometimes dangerous event. People in crisis may pose such a danger to themselves or others that restraints may seem necessary, but more often than not, restraints are overused by default. Children with mental health concerns should not be restrained mechanically and certainly not handcuffed when being transported in the community – especially out of school. Before restraints are utilized, respondents to a mental health crisis should use de-escalation techniques, work with support systems available to promote compliance and voluntary treatment, and if a person voluntarily agrees to be transported to another location, use no restraints at all. Compliance protects both the person and others and is less traumatizing and physically harmful to the person.

Attending to the Mental Health Needs of Law Enforcement Personnel

Law enforcement jobs are often quite stressful, particularly in the high-crime neighborhoods in which too many persons with mental illness must live. Job stress often leads to Post-Traumatic Stress Disorder (PTSD) and other serious mental illnesses.[18] One of the common symptoms of untreated PTSD is hyper-vigilance, which causes an exaggerated perception of danger and makes it difficult to respond with care and restraint to an encounter with a person in mental health crisis. The high rate of mental health conditions among police is demonstrated by the high rate of suicide, divorce and substance use problems.[19] Unless the police are healthy, it is unrealistic to expect them to demonstrate consistent and appropriate responses to difficult and sometimes life-threatening situations. Insuring that police officers are appropriately screened, diagnosed and treated is made more difficult by a police culture which often views mental illness as a weakness which cannot be acknowledged to peers or supervisors. Police departments must recognize the mental health needs of officers, must carefully screen officers and must develop strategies to engage them in treatment.

Call to Action

• Communities should ensure that incentives and resources are aligned to most effectively provide effective crisis intervention. Communities should engage in coordinated efforts to identify and provide those services necessary to prevent behavioral health crises. These efforts must include not only better mental health and substance abuse services, but also a recognition of the role of unemployment, poverty and homelessness in behavioral health crises.
• Emergency (911) operators and dispatchers should be trained to recognize and to respond appropriately to behavioral health crises.
• Communities should develop alternatives to law enforcement involvement in behavioral health emergencies. These alternatives should include: crisis lines or other technology which specialize in responding to mental health emergencies, alternatives to using law enforcement (such as peer-led mobile crisis teams) to transport persons to needed mental health services and a wider array of crisis services as alternatives to police custody and hospitalization, including peer-run crisis respite and psychiatric urgent care.
• All law enforcement personnel should have training in how to respond to persons in behavioral health crises. Crisis Intervention Team (CIT) training should be provided to police officers so that officers with CIT training are available on every shift. CIT training and implementation should incorporate collaboration with local mental health providers and advocates.
• Police departments must attend carefully to the mental health and substance use needs of officers. Policies must be in place which encourage officers to seek help in responding to the stressful nature of their work, employ appropriate screening tools to help identify officers who need mental health and substance use services and insure that police officers are fit for duty.
• When the police must transport someone to an emergency department or other mental health providers, responders should refrain from using restraints and handcuffs unless they are absolutely needed to prevent harm to self or others.
• The police should function as part of a coordinated effort to divert persons away from the criminal justice system and into appropriate mental health and substance use disorder services. (For the role of law enforcement in diversion, please see MHA Position Statement 52.[20])
• Incentives should reward successful diversion, such as by allowing law enforcement to share in the savings that accrue from reduced incarceration and better health care outcomes.

Effective Period

The MHA Board of Directors adopted this policy on March 3, 2017.   It will remain in effect for a period of five (5) years and is reviewed as required by the MHA Public Policy Committee.

Expiration: December 31, 2022