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Frequently Asked Questions

FAQs

The vast majority of people with mental illness who come in contact with the criminal justice system are arrested for minor, non-violent offenses like public intoxication, loitering, and petty theft. Nonetheless, there are times when people, whether they have criminal justice histories or not, can become violent. Having policies and procedures and appropriate staff training can help to increase the likelihood of safe encounters in times of crisis.

Safety protocols should carefully outline responsibilities of staff in times when violence is possible. Protocols can be developed in collaboration with law enforcement agencies that have significant experience designing spaces to prevent crime and foster safety. Behavioral health facility staff should conduct initial clinical screenings to assess for risks of violence and harm to self. Protocols should cultivate teamwork and vigilance in detecting and addressing potentially dangerous situations. They should foster a sense of urgency, but deter full-blown panic. Protocols should also clearly outline the debrief and follow-up process after the situation is resolved. Role playing crisis scenarios can also help build staff confidence in their management of crisis situations and reinforce written protocols.

For More Information:

The vast majority of people with mental illness who come in contact with the criminal justice system are arrested for minor, non-violent offenses like public intoxication, loitering, and petty theft. Nonetheless, there are times when people, whether they have criminal justice histories or not, can become violent. Having policies and procedures and appropriate staff training can help to increase the likelihood of safe encounters in times of crisis.

Safety protocols should carefully outline responsibilities of staff in times when violence is possible. Protocols can be developed in collaboration with law enforcement agencies that have significant experience designing spaces to prevent crime and foster safety. Behavioral health facility staff should conduct initial clinical screenings to assess for risks of violence and harm to self. Protocols should cultivate teamwork and vigilance in detecting and addressing potentially dangerous situations. They should foster a sense of urgency, but deter full-blown panic. Protocols should also clearly outline the debrief and follow-up process after the situation is resolved. Role playing crisis scenarios can also help build staff confidence in their management of crisis situations and reinforce written protocols.

For More Information:

People with mental health needs who are in the criminal justice system are often defined by certain common factors including a history of antisocial behavior, antisocial defenses, antisocial associates, substance use, lack of benefits (e.g. health insurance), and a poor social support system. Developing a therapeutic relationship with someone in the criminal justice system may be initially influenced by suspicion and mistrust, making it difficult to establish the person-clinician rapport essential for the recovery process. However, evidenced-based recovery models and treatment interventions have been developed or modified to address these unique challenges and needs.

For example, specific evidenced-based Cognitive-Behavioral Interventions have been modified to address the criminogenic risk factors associated with recidivism. Components include identifying one’s feelings, paying attention to and restructuring one’s thinking, examining the consequence of choices made, and behavior modification through social skill building, modeling, pro-social behavioral rehearsal, and assignments. While these interventions were initially developed for the general population, modifications have been made that accommodate the unique needs of people with serious mental illnesses reentering the community.

For More Information:

When an individual is in mental health crisis, the initial response to the crisis is commonly provided by a law enforcement officer and not a behavioral health care provider. Because of these responses, the overwhelming evidence to date indicates that a significant number of people who are in the criminal justice system have behavioral health needs – mental, substance use, or co-occurring disorders. And typically, even a large proportion of people receiving treatment in community mental health centers are, or previously were, in the criminal justice system.

Behavioral health providers are uniquely qualified to work with people in mental health crisis, no matter the setting, and can help reduce the number of people with mental illnesses in the criminal justice system because they are trained to identify and treat behavioral health disorders and intervene to increase support, improve wellness, and promote recovery. Additionally, crimes committed by people with mental illnesses are often related to their condition or associated circumstance, and therefore those who commit minor crimes would be better served through treatment in a behavioral health setting rather than incarceration.

For More Information:

It is vitally important for the chief to take an active leadership role in implementing agency-wide strategies to deal with persons coping with mental health issues or intellectual/developmental disabilities.

Police leaders need to focus on data-driven strategies to find effective solutions. There are many questions a chief needs to answer before moving forward, including the number of calls for service involving people with mental illnesses, available resources, training, information-sharing and privacy issues, and more.

To have successful interactions, the chief must be at the forefront as a leader on this issue, along with ensuring successful buy-in from officers throughout the agency, and strong, effective partnerships with mental health professionals. The PMHC program must be incorporated into agency goals and made an operational priority, taking its place on the chief's "dashboard." Support from all staff, top-to-bottom, is necessary for the efficacy and success of the PMHC program.

Issues related to people with mental illness need champions within the police agency, or else they run the risk of falling through the cracks. Some police agencies appoint an officer or commander to oversee the planning and implementation of the initiative. In addition, they serve as the agency's primary liaison with mental health providers and other stakeholders. These liaison officers can be particularly effective for problem-solving location-specific issues to reduce and prevent crimes, disorder, and calls for service at current and potential hot spots.

For additional information see:

http://www.cityofmadison.com/police/chief/blog/?Id=9167

http://www.houstoncit.org/

https://www.facebook.com/loudounsheriff/posts/10153944549281977

​Approximately 1 in 5 adults in the U.S.—43.8 million, or 18.5%—experiences mental illness in a given year, and approximately 1 in 25 adults in the U.S.—10 million, or 4.2%—experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities (National Alliance on Mental Illness). 

The number of contacts law enforcement has with people with mental illnesses varies by community, and can be hard to document if the calls are not properly identified and coded.  An estimated 7 percent of police contacts in jurisdictions with 100,000 or more people are with individuals with mental illness (Deane, et al.). The majority of these encounters are with individuals suspected of committing low-level, misdemeanor crimes, or who are exhibiting nuisance behavior. Many communities report that the number of contacts has been increasing, sometimes precipitously, in recent years (San Diego Association of Governments).

People with mental illnesses, most of whom have co-occurring substance use disorders, are over-represented at every stage of the criminal justice system. Researchers documented serious mental illnesses in 14.5 percent of males in jail and 31 percent of females in jail (Steadman, et al.); these rates are more than three to six times those found in the general population (Kessler, et al). Generalized to the fact that almost 13 million jail admissions occur annually, more than 2 million bookings of people with serious mental illnesses occur annually (Snyder, et al).

For additional information see:

National Alliance on Mental Illness, "Mental Health by the Numbers," http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers

M. W. Deane, H. J. Steadman, R. Borum, B. M. Veysey, J. P. Morrissey, "Emerging Partnerships between Law Enforcement and Mental Health," Psychiatric Services, January 1999 Vol. 50 No. 1. http://www.popcenter.org/problems/mental_illness/PDFs/Deane_etal_1999.pdf

San Diego Association of Governments, "Mental Health Calls for Service to Law Enforcement Continue To Increase – Possible Reasons and Possible Solutions from the Field," May 2016. http://www.sandag.org/uploads/publicationid/publicationid_2040_20740.pdf

H. J. Steadman, F. C. Osher, P. C. Robbins, B. Case, and S. Samuels, "Prevalence of Serious Mental Illness among Jail Inmates," Psychiatric Services 60, no. 6 (2009): 761-765. http://www.pacenterofexcellence.pitt.edu/documents/PsySJailMHStudy.pdf

R. C. Kessler, C. B. Nelson, K. A. McKinagle, M. J. Edlund,  R. G. Frank,  and P. J. Leaf, "The Epidemiology of Co-Occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization," American Journal of Orthopsychiatry 6 (1996): 17–31.

H. N. Snyder, W. J. Sabol, T. D. Minton, "Arrest in the United States, 1990–2010," (Washington, DC: Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2012). http://www.bjs.gov/content/pub/pdf/aus9010.pdf​​

Though tragic and violent incidents involving people with mental illness are rare, they draw intense media and public attention. This creates misperceptions about the relationship of mental illness to violence and unfortunately increased stigma and discrimination. There is no doubt that many individuals with mental illnesses who commit violent crimes must be held responsible for their actions. However, it is important to remember that most violence in this country is not committed by people who have a mental illness, and most people with mental illnesses are not violent.

The risk of violence statistically attributable to serious mental illness is estimated to be 3 to 5 percent; this is comparable to rates among persons without mental illnesses (Friedman). Because serious mental illness affects a small percentage of the population, it makes— at most—a very small impact on the overall level of violence in society. In fact, people with serious mental illnesses are anywhere from 2.5 times to nearly 12 times more likely to be victims rather than perpetrators of violence (Choe, et al; and Hiday, et al.).

For additional information see:

Richard A. Friedman, "Violence and Mental Illness—How Strong is the Link?" New England Journal of Medicine 355 no. 20 (2006), 2064–2066.  http://www.nejm.org/doi/full/10.1056/NEJMp068229#t=article

J.Y. Choe, L. A. Teplin, and K. M. Abram, "Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns," Psychiatric Services 59, no. 2 (2008): 153–164.            

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3756896/

V.A. Hiday, J.W. Swanson, M.S. Swartz, R. Borum, and H.R. Wagner, "Criminal Victimization of Persons with Severe Mental Illness," Psychiatric Services 50, no. 4 (1999): 62–68.

http://ps.psychiatryonline.org/doi/full/10.1176/ps.50.1.62

When discussing people with mental illnesses in criminal justice settings, it is important to keep in mind the heterogeneity of this group. They differ in their demographics, seriousness of their mental illnesses, charge levels, access to commu​nity supports, and criminogenic risks (i.e., the factors that affect how likely they are to engage in criminal behavior). There are three primary factors that drive law enforcement encounters with people with mental illnesses: homelessness and visibility, substance use, and limited access to mental healthcare.

First, people with mental illnesses are over-represented in homeless populations and, as such, they are more visible to law enforcement. Their problematic behaviors (e.g., public disturbance, panhandling and public intoxication), which stem from lack of treatment, attract attention. As an indicator of how visibility may play a role in their arrest: incarcerated persons with mental illnesses are much more likely to have been homeless at the time of their arrest than those without mental illnesses (Ditton).

Second, people with mental illnesses are about three times more likely to develop a co-occurring substance use disorder than the general population (Reiger, et al.). This increased prevalence of substance use disorders over the course of their lifetimes, combined with an overall increase in arrests for drug-related offenses, means that more people with mental illnesses will be arrested. Research has found that nearly three-quarters of men and women with mental illnesses in jails also have a co-occurring substance use disorder (Abram and Teplin).

Third, the limited access to over-burdened community-based treatment may make individuals with untreated symptoms more likely to be arrested. Individuals with mental illness who encounter police are too frequently incarcerated—often for misdemeanant or non-violent infractions—rather than connected with treatment services, simply because of a lack of community resources. If there are no alternatives to incarceration for people with a serious mental illness, officers feel that their only option is to book that person into jail to ensure their safety.

For additional information see:

Paula Ditton, "Mental Health and Treatment of Inmates and Probationers," (Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1999). http://www.bjs.gov/content/pub/pdf/mhtip.pdf

D. Hasin and B. Kilcoyne, “Comorbidity of psychiatric and substance use disorders in the United States: current issues and findings from the NESARC,” Current Opinion in Psychiatry 25 no. 3 (May 2012): 165–171. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767413/pdf/nihms506515.pdf

K. M. Abram and L. A. Teplin, "Co-Occurring Disorders among Mentally Ill Jail Detainees: Implications for Public Policy," American Psychologist 46, no. 10 (1991) 1036-45. http://www.ncbi.nlm.nih.gov/pubmed/1746771

German Lopez, "How America's Criminal Justice System became America's Mental Health System,"

Vox.com, March 1, 2016. http://www.vox.com/2016/3/1/11134908/criminal-justice-mental-health

A thorough program evaluation will require the allocation of resources to analyze the data collected. Agencies with planning and research divisions may want to identify agency staff and allocate a percent of their time during the program design phase to coordinate or conduct these evaluations. Agencies without research capacity may benefit from outside assistance in aggregating, deciphering, and interpreting the data to determine program effectiveness.

Because of the challenges associated with data collection, as well as the difficulties in analyzing often incomplete data, many law enforcement agencies partner with a local college or university to assist with this process. Academic partners may require compensation for which law enforcement agencies may need to find sources of support, including submitting joint grant proposals. If the agency chooses to engage an external research partner, these outside teams will need to work closely with law enforcement and their collaborators during the evaluation process, and this staff time commitment should be considered at the planning stage.

Law enforcement agencies should designate a staff person who will work with a subcommittee on evaluation issues. In addition to helping to ensure that all agencies that are contributing data are using sound and accurate collection and reporting practices, this group can determine how the evaluation results will be used, how they will be disseminated, and who should review interim reports and the interpretations of the data.

For additional information see:

Measuring Excellence: Planning and Managing Evaluations of Law Enforcement Initiatives

Performance measurement is a management tool for monitoring a program on a regular and on-going basis. It is typically conducted by program or agency managers and is part of an agency's management information system used to monitor progress on a variety of law enforcement activities and indicators.  Performance measurement focuses on whether a program has achieved its objectives, expressed as measurable performance standards. Performance measures may address the type or level of program activities conducted (process), the direct products and services delivered by a program (outputs), and/or the results of those products and services (outcomes).

Program evaluations take a longer view and provide more detailed information for policy and program decisions. Program evaluations typically examine a broader range of information on program performance and its context than is feasible to monitor on an ongoing basis. Often, program evaluations are conducted by, or in collaboration with, and external evaluator, such as college professor.  The program evaluation should contain both a process assessment as well as an assessment of outcomes. This will allow revisions to the activities that may be experiencing difficulties and to enhance those that are effective, as well as to provide proof of the program's success to foster sustainability.

For both performance measure and program evaluations data should be collected for both process and outcome measures. Evaluating a program's process will allow managers to assess whether the proposed activities are being carried out (how many individuals were trained, how many calls were answered by an officer with training, and more).

For additional information see:

Key Concepts and Issues in Program Evaluation and Performance Measurement

Measuring Performance in a Modern Police Organization

The primary challenges law enforcement faces include cumbersome data collection systems and the sheer volume of police activity that can be counted and categorized. Some specific challenges include:

  • Computer-Aided Dispatch (CAD) systems categorize calls for service and attach codes to the call types. Not all CAD systems have mental health call codes.
  • Codes can be limited in their ability to track mental health calls because complaints involving people with mental illness often are described in other terms, such as "suspicious activity," "welfare check," or "disturbance." When calls are coded imprecisely it is difficult to count the true number of mental health calls.
  • Changing or adding codes to allow for more accurate coding of calls can be restricted by the type of CAD system being used or the cost to program new codes.  Changing codes can also be problematic when the law enforcement agency does not have oversight of the emergency communications center, but must rely on others to authorize those changes.
  • Records Management (RM) systems are the repository for officer incident reports, which include detailed information about certain calls for service. However, CAD and RM systems usually use different operating systems, making it difficult to match call for service data to incident reports and to track information on an incident from initial call to final disposition.
  • Officers have an enormous amount of documentation to complete and information to record, and may be resistant to completing additional forms—such as those required for collecting more detailed information on incidents involving people with mental illnesses.
  • Officers may not always be clear about when to re-code calls that involve a person with mental illness, or what information to include in reports either because of a lack of training or lack of policies to guide them.
  • Many agencies use paper-based forms to collect information (as compared to use of mobile data computers), which require many person hours to enter and analyze.
  • Many agencies that are able to collect data often lack trained (or appropriate) personnel to conduct analyses of the data.

For additional information see:

International Association of Chiefs of Police CAD-RMS resources

Reliable data is essential for demonstrating PMHC program activities and performance, ensuring that scarce resources are effectively managed, demonstrating to government decision-makers that the program is meeting its goals, requesting funding through annual budgets or grants, and garnering the support of behavioral health providers and other community stakeholders. Lacking the ability to collect data inhibits the ability of agencies to measure performance.

Some of the frequently used performance measures that rely upon data include:

Process measures:

  • Officers trained
  • Training effectiveness
  • Officers selected as PMHC specialists
  • Policies developed
  • MOUs developed

 Operational measures:

  • The number  of calls for service involving people with mental illnesses
  • Duration of calls for service
  • Percentage of calls that specially trained personnel handle
  • Repeat calls for the same individuals
  • Repeat locations for mental health calls
  • Frequency of disposition decisions
    • resolve at scene
    • provide referral to behavioral health resources
    • transport for voluntary treatment
    • involuntary examination and hold
    • arrest
  • The frequency of use of force during mental health calls
  • The number of injuries or fatalities to officers, consumers and third parties

Each PMHC program should determine the specific goals and objectives that will guide the data collection process. Then, law enforcement and their partners can identify what information is needed to demonstrate whether progress towards these goals has been made and determine the best method to collect this data.

Many existing data sources—such as Computer-Aided Dispatch (CAD) data, incident reports, jail admissions, emergency medical services (EMS) logs, and emergency room records—can provide useful information, although there are challenges associated with extracting the needed data because these data systems typically were designed to capture information for purposes other than PMHC performance measurement or program evaluation.

Individuals with mental illnesses who come into contact with law enforcement often require an array of services and supports such as medication management, counseling, substance abuse treatment, benefits and financial management, housing, crisis services, peer supports, case management, and inpatient treatment. Several of these services are beyond the immediate concerns of officers when they transfer custody of a person t​o mental health providers, but PMHC program managers should work with community providers to understand how these services might influence the availability of diversion options for officers.

PMHC program managers and mental health counterparts should identify ways to improve access to mental health services when officers transfer a person with mental illness. This may entail streamlining the custody transfer process at a mental health intake facility. Law enforcement should have easy access to twenty-four-hour drop-off facilities or emergency rooms to facilitate the individual's swift access to mental health services and allow officers to return quickly to duty. The necessity of medical clearance requires program managers to develop procedures that guarantee timely assessment, ensure the safety of other patients and staff, and facilitate a smooth transition to the appropriate mental health resource.

Because many individuals with mental illnesses who come into contact with law enforcement have co-occurring disorders (having both mental health disorders and substance use disorders), the availability of integrated treatment approaches is essential to achieve clinical and public safety objectives. PMHC program managers and mental health counterparts should consider how the PMHC program can connect individuals with co-occurring disorders to integrated treatment and should advocate for greater access to evidence-based practices for those dually diagnosed.

Special considerations include histories of trauma which are common in justice-involved populations. As such, both the on-scene response of law enforcement and subsequent clinical responses must be trauma informed. PMHC program managers and mental health counterparts should pay special attention to the service needs of racial and ethnic minorities and women by making culturally competent and gender-sensitive services available to the extent possible.

The sharing of information between law enforcement and mental health providers is a necessary component to a successful PMHC program. By opening doors for communication and outlining procedures on how to do so, the information-sharing agreement provides a framework for the PMHC program team and mental health providers to collaborate. Uncertainty about legal requirements is lessened and common goals are introduced allowing outcomes to improve.

Information-sharing decreases disruption in and duplication of healthcare services and therefore results in longer periods of mental health stabilization. This in turn causes a decline in the individual's involvement in criminal activity and subsequent repeat calls for service. Ultimately, information-sharing assuages the cost of care absorbed by the healthcare and criminal justice systems and law enforcement.

Information should be shared when it increases safety to the individual, staff, and public. It should also be shared to improve access to and quality of mental healthcare, e.g. to help mental health providers make sound treatment decisions including appropriate referrals and interventions. The information-sharing agreement is not meant to facilitate sharing for purposes of research, or to aid in an investigation.

It is important for the agreement to be in writing. As information will inevitably be shared, a written agreement decreases the opportunity for a legal violation of information-sharing law, thereby decreasing liability. Additionally, written protocols transforms information-sharing efforts from being voluntary to mandatory. By lessening confusion which stems from "inherited" verbal protocol, an agreement is more likely to stand the test of time if it is in writing.

The agreement should state the purpose of sharing information and outline procedure to do so. It should discuss the obligations of both parties, describe associated training, and provide provisions for oversight and sustainability.

The dispatch function plays a critical role in PMHC programs by providing information about calls to officers, and then documenting the number of mental health calls and their dispositions. Agencies should focus on five steps to align the dispatch function with the PMHC program.

Train call takers and dispatchers in mental health knowledge and gathering critical information

Specialized training for call takers and dispatchers is critical to officer and consumer safety. This training provides tools to identify calls that may involve a person with a mental illness, gather important information about the situation from the caller (for example the person's previous reactions to law enforcement, the person's medication status, any history of violence) and provide that information to responding officers.

Provide dispatchers with questions that help determine whether mental illness is relevant to the call for service.

Dispatchers should use a small number of standardized questions to aid the information-gathering process. These questions should also assess, when possible, if co-occurring disorders (having both mental health disorders and substance use disorders) or other issues are relevant to the call for service. For example, dispatchers in the Harris County (TX) Dispatch Center ask every caller two questions:

  1. Are you aware of or does the person have mental health issues?
  2. Is this call in reference to the person's mental state?

Provide dispatchers with tools that determine whether the situation involves violence or weapons.

As in all calls, dispatchers should gather information to assess safety issues that the responding officer might encounter, including whether weapons are involved, whether the person poses a danger, if the person with mental illness is at risk of being victimized, and whether there is a history of violence. Some agencies "flag" certain locations in the Computer Aided Dispatch (CAD) system, and when dispatching the call, provide this additional information to the responding officers.

Provide dispatchers with a flowchart to facilitate dispatch of the call to designated personnel.

Dispatchers should be given a flowchart that states clearly who should respond when calls for service may involve people with mental illnesses. Dispatchers should provide all of the essential information to the appropriate responding officer, including whether mental illness may be a factor, so that officers are able to respond effectively to a call for service.

Use designated codes and appropriate language when dispatching the call.

Whether using a 10-code system, "plain speech," or a combination of the two when dispatching calls for service over the radio, officers should be provided meaningful information on the type of call to which he or she is responding as a means of protecting the safety of both the officer and the consumer. Dispatchers and officers should use only designated codes and/or appropriate language when communicating over the radio. Properly identifying mental health calls for service is critical to measuring the number of calls, their location throughout the jurisdiction by time and geography, and the identification of repeat encounters.