Mental Health Issues Discussion

CNS Spectrums (2020), 25, 181–195. © Cambridge University Press 2019 doi:10.1017/S1092852919001640 REVIEW ARTICLE Decriminalizing mental illness: specialized policing responses Charles Dempsey1, Cameron Quanbeck2* , Clarissa Bush3 and Kelly Kruger4 1 Crisis Response Support Section, Mental Evaluation Unit, Administration-Training Detail, Los Angeles Police Department, Los Angeles, California, USA Cordilleras Mental Health Rehabilitation Center, San Mateo County Health, San Mateo, California, USA 3 Zuckerberg San Francisco General Hospital, University of California San Francisco School of Nursing, San Francisco, California, USA 4 San Francisco Police Department, San Francisco, California, USA 2 De-institutionalization of mental health patients has evolved, over nearly 3 generations now, to a status quo of mental health patients experiencing myriad contacts with first-responders, primarily police, in lieu of care. The current institutions in which these patients rotate through are psychiatric emergency units, emergency rooms, jails, and prisons. Although more police are now specially trained to respond to calls that involve mental health patients, the criminalization of persons with mental illness has been steadily increasing over the past several decades. There have also been deaths. The Crisis Intervention Team (CIT) model fosters mental health acumen among first responders, and facilitates collaboration among first responders, mental health professionals, and mental health patients and their families. Here, we review some modern, large city configurations of CIT, the co-responder model, the mitigating effects of critically situated community-based programs, as well as barriers to the success of joint efforts to better address this pressing problem. Received 01 April 2019; Accepted 27 September 2019; First published online 29 November 2019 Key words: Mentally ill persons, crisis intervention, police education, interprofessional relations, diversion, emergency services. Introduction The criminalization of persons suffering from a mental illness continues to be a urgent public health concern, a resource-draining criminal justice problem, and an overarching societal issue, not only in the state of California, but also across the United States and the world. Mental Health Issues Discussion

With the advent of deinstitutionalization, which was codified by the Lanterman-Petris-Short Act (Cal. Welf & Inst. Code, sec. 5000 et seq.) in 1967 in the State of California and subsequent legislations across the nation, states could no longer simply lock a person with mental illness away in a mental health facility or sanitarium, which violated their constitutional right to due process. The intent of the LantermanPetris-Short Act was to move away from the numerous state-run institutions and create a community-based treatment model, providing mental health services in least restrictive environments. Although the intent of de-institutionalization had its merits, it created an unfunded mandate and then a capacity crisis at most * Address correspondence to: Cameron Quanbeck, Cordilleras Mental Health Rehabilitation Center, San Mateo County Health, San Mateo, California, USA. (Email: cquanbeck@smcgov.org) Psychiatric Emergency Departments and Medical Emergency Rooms across the country. De-institutionalization shifted access to mental health services and treatment predominantly to “first responders,” who became the primary means by which persons in a mental health crisis were contacted, de-escalated, detained, and transported for mental health treatment.1 Law Enforcement/First Responder Diversion Models Many states modified their laws giving law enforcement the power to detain and involuntarily transport those persons with a serious mental illness from their homes or the street to facilities in order to treat their mental illness.2 Across the United States and in many other nations, these powers are based in the legal standard of probable cause, wherein the person contacted is believed to be suffering from a mental disorder that is acute, and as a result the person is a danger to self, others, and or gravely disabled and unable to care for their basic needs. The shift to deinstitutionalization has led to the criminalization of those with a serious mental illness and the role law enforcement plays in this process is well-documented. Downloaded from https://www.cambridge.org/core. University of South Florida Libraries, on 12 May 2020 at 22:45:21, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852919001640 182 C. DEMPSEY ET AL. Most law enforcement agencies, who were now codified by state laws to handle calls involving persons with mental illness, were ill-prepared to manage this shift of responsibility. The lack of promised community supports and services left officers with few choices in the management of these calls involving persons with serious mental illness, resulting in their arrests and subsequent housing in jails and prisons.3 This shift in the role of the first responder in managing crisis mental health calls ultimately led to several tragedies in which a person with a mental illness died as a result of the involvement of law enforcement. These tragedies led to the inception of two law enforcement-based response strategies or Specialized Policing Responses.4 The first strategy is the Crisis Intervention Team (CIT) model (more commonly known as the “Memphis Model”), a “first responder” law-enforcement based model. This model (developed in 1988 in Memphis, Tennessee) is widely accepted nationally and has become an important safety net and crisis intervention strategy in many communities, where access to mental health services or the lack thereof has fallen on first-responders.5 Now available in 2700 communities nationwide, CIT programs create connections between law enforcement, other first responders (eg, paramedics, dispatchers), mental health professionals, and persons suffering from a serious mental illness and their family members. A typical CIT program involves an intensive 40 hour/week training during which participants learn how to recognize symptoms of major mental illness, interact, and gain perspective from those who have experienced mental health crises and their families, engage in role-playing exercises that help enhance verbal de-escalation skills, and visit sites in the community where follow-up care is provided after a law enforcement referral is made for treatment services. Research on the effectiveness of CIT training has examined changes in outcomes before and after CIT training and compared outcomes of crisis calls for officers with CIT training to those without training. CIT training increases the likelihood that an officer will divert a person suffering from a mental illness who has committed lowlevel offenses to mental health services as opposed to jail.6–8 Referrals for treatment rather than arrest can be effective in re-establishing regular mental health contact in persons experiencing mental health crises, many of whom have disengaged from mental health care in the year prior to the crisis.9 Diverting and reconnecting individuals to community mental health services rather than making an arrest is cost-effective because it avoids expensive inpatient referrals from a jail to a psychiatric facility for competency restoration.10 Research has shown that CIT training changes officer attitudes more favorably toward persons with a mental illness,6 enhances knowledge about mental health conditions,7 an d improves skill in de-escalating crisis situations using verbal engagement and negotiation. Mental Health Issues Discussion

8 These important learning strategies are designed to increase empathy toward persons suffering from a mental illness. When dealing with persons exhibiting psychotic agitation, CIT-trained officers have increased awareness that physical interventions are likely to be ineffective and are less likely to use force,11,12 as well as an appreciation that the behaviors exhibited by persons with schizophrenia have biological causes.13 A training approach that is widely accepted as effective in CIT training programs are role-playing exercises during which police officers interact with actors presenting with psychiatric-related behaviors commonly encountered in the field.14 Law enforcement officers who have received feedback during role-playing exercises have an increased ability to recognize mental health issues as a reason for a call, deal with mental health issues more efficiently, and decrease their use of weapons use physical force in interactions with persons with mental illness.15 Although the CIT training model has been a useful tool in diversion of persons with serious mental illness from criminal justice settings, a major limitation is the CIT officer’s lack of formal mental health training. In a study comparing ability to recognize signs and symptoms of mental illness in a variety of clinical scenarios, graduate students in mental health fields recognized the presence of mental disorders twice as often as CIT-trained officers.16 Furthermore, CIT officers do not have clinical backgrounds and connections to mental health resources in the community that can facilitate linking the appropriate treatment to an individual with mental illness encountered in the field. Lastly, even when officers recognize the symptoms of a mental illness and are familiar with the resources within their communities, it is the lack of those resources which can limit the ability of officers to divert the person who is suffering from a mental illness from the criminal justice system. The second law enforcement response strategy that evolved shortly after CIT is known as the “Co-Responder Team (CRT).” This is a “secondary” response model, in which a specially trained officer and a mental health clinician respond to the person in crisis, after being contacted by uniformed patrol officers. Typically, these teams are dispatched and ride together in a police vehicle. This strategy was first employed by the Los Angeles County Sheriff’s Department in 1992, known as Mental Evaluation Team, and in 1993 by the Los Angeles Police Department (LAPD), when it began deploying the Systemwide Mental Assessment Response Teams (SMART).17 CRT provides emergency assessment and referral for individuals with mental illness who come to the attention of law enforcement through phone calls from community members or in-field law enforcement requests for emergency assistance. The mental health clinician has access to the information from the community’s mental health Downloaded from https://www.cambridge.org/core. University of South Florida Libraries, on 12 May 2020 at 22:45:21, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852919001640 SPECIALIZED POLICING RESPONSES 183 TABLE 1. Mental Health Issues Discussion

Proposed levels of care of the Behavioral Health Justice Center: diversion of mentally ill individuals from the criminal justice system into treatment in San Francisco Level 1 Level 2 Level 3 Level 4 Emergency Mental Health Reception Center and Respite Beds. A 24-hour venue for police to bring individuals experiencing a mental health episode for an initial mental health assessment. Short-term (2–3 wk) transitional housing and on-site residential treatment. Long-term Residential Dual Diagnosis Treatment. Longer-term intensive residential psychiatric care and substance abuse treatment in an unlocked setting. Secure Inpatient Transitional Care Unit. Short-term, voluntary inpatient treatment for persons with mental illness transitioning to community-based residential treatment programs. system and the law enforcement officer can access past contacts with law enforcement and the local jail. The CRT evaluates the crisis, assesses the individual’s mental health condition and current needs, and, as indicated, transports persons to a hospital, or refers them to a community-based resource or treatment program. The addition of a skilled and experienced mental health clinician at the scene of a crisis call has been shown to enhance positive outcomes for persons with mental illness. Compared to police-only interactions with those in mental health crises, CRT interactions had lower rates of injury and arrest, more voluntary transports to a hospital, less time at the hospital during handover to staff,18 as well as less time spent on-scene.19 In contrast to police- only response, CRT teams can admit individuals directly to inpatient psychiatric units20,21 and are significantly better able to manage mental health crises in outpatient mental health settings, avoiding unnecessary hospitalization.18 Service users of CRTs see the benefit of a joint mental health professional/police officer team response to crisis calls in the community.22 Compared to the police-only response, CRTs offered improved communication, de-escalation skills, information sharing, interagency collaboration, and a greater likelihood of consumers achieving a preferred outcome to their mental health crisis.20 A Los Angeles County study examined differences in treatment outcomes of 15,454 mentally individuals encountered by LAPD patrol officers and LAPD’s CRT (SMART team) over a 1-year time period. The overwhelming majority (90%) of persons with mental illness contacted by LAPD patrol officers were taken to Los Angeles County psychiatric facilities; in contrast, 60% of those in a mental health crisis seen by SMART were taken to a private psychiatric facility or urgent care center.23 This clearly demonstrates the ability of CRTs to provide better placements for those experiencing a mental health crisis. CIT and Co-Responder models are widely accepted as “best practices” across the United States and the world in the ongoing effort to reduce the population of those suffering from a serious mental illness from being housed in our city jails and prisons. Unfortunately, despite these successes, the criminalization rate of persons with mental illness has continued to rise over time. Sequential Intercept Model/Community-Based Mapping As communities continued to struggle with this insidious public health and public safety issue, there was no clear understanding of how, when, and where persons with a serious mental illness engaged, entered into, traversed, and exited the criminal justice system (usually worse -off than before criminal justice involvement). It was at this point that the Sequential Intercept Model was introduced (Figure 1)24 developed as a conceptual model to inform community-based responses to the involvement of people with mental and substance use disorders in the criminal justice system. Developed over several years in the early 2000s by Mark Munetz, MD and Patricia A. Griffin, PhD, along with Henry J. Steadman, PhD, of Policy Research Associates, Inc the Sequential Intercept Model identified 5 key intercepts in which an individual suffering from a mental illness intersects and navigates the criminal justice system. Intercept 1 is law enforcement in the community setting, which involves the initial 911 call for service and a law enforcement response. Intercept 2 is the initial arrest/detention and first court appearance. Intercept 3 is the process through the jails and courts to include sentencing. Intercept 4 is re-entry from jail or prison. Finally, Intercept 5 involves community correction, such as probation and parole. Mental Health Issues Discussion

The Sequential Intercept Model became the road map many communities utilized, for those who were engaged in the process of diversion, assuming that diversion begins with Intercept 1 and a law enforcement contact. Recently, the developers of the Sequential Intercept Model added an Intercept 0, which focused on community-based services being the first or preferred contact with a person who is suffering from a serious mental illness, hopefully in a pre-crisis situation (Figure 2).25 By adding Intercept 0, this reinforced the pre law enforcement contact and understanding that community engagement is a valid intercept, preventing that initial law enforcement contact in the first place. Early intervention points in the community include crisis hotlines, coordination of community dispatchers with law enforcement, mobile and peer crisis services, devoted psychiatric emergency rooms, and short-term crisis residential stabilization units. Downloaded from https://www.cambridge.org/core. University of South Florida Libraries, on 12 May 2020 at 22:45:21, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852919001640 184 C. DEMPSEY ET AL. Downloaded from https://www.cambridge.org/core. University of South Florida Libraries, on 12 May 2020 at 22:45:21, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852919001640 FIGURE 1. The Sequential Intercept Model at first identified 5 key intercepts: Intercept 1—law enforcement; Intercept 2—initial detention/initial court hearings; Intercept 3—jails/courts; Intercept 4—re-entry; and Intercept 5—community corrections. SPECIALIZED POLICING RESPONSES Community Education In his Master’s thesis paper titled, “A Descriptive Study of LAPD’s Co-Response Model for Individuals with Mental Illness” Hector Lopez made a fascinating observation. He noted that the African-American community in the City of Los Angeles disproportionately relied on 911 to access mental health services, and usually after a crisis had occurred.23 What he discovered was that (in an effort to promote public safety) governments and communities have created a default response to mental health-related crises, thus assuring a de-facto first responder/law enforcement response to all community mental healthrelated situations. This, in turn, leads the public to believe that this is the appropriate best response. Because of this finding, the LAPD, with the cooperation of the Los Angeles County Department of Mental Health (LACDMH) and with feedback from the National Alliance on Mental Illness (NAMI), created its 911 checklist. This checklist provided the community and family members 3 basic messages: (1) if they must call 911, what information the dispatcher needs; (2) what to expect when the police respond; and (3) if it is not a true emergency refrain from calling 911. In addition to the 911 checklist, they are also provided the LAPD—LACDMH Community Mental Health Resource Guide. Mental Health Issues Discussion

26 These are distributed by responding officers to 911-related mental health crisis calls, at community meetings, and at NAMI support group meetings. Los Angeles is not alone in this effort of educating communities; others such as Dallas and Houston have developed similar efforts and tools.27–29 The goal is to educate community members, families, and others to address the needs of a person suffering from a mental illness in the community pre-crisis setting, Intercept 0. It is believed that collaboration, awareness, and education of the community and families will result in fewer contacts between law enforcement and those suffering from a serious mental illness and increase awareness of those community mental health and housing resources available to those who suffer from a serious mental illness. Mental Health Issues Discussion

911 Call Diversion and Other Non-Law Enforcement Strategies In addition, some communities such as Houston and Harris County, Texas have come to realize that not all mental health crisis calls are equal, and many do not require the response of law enforcement. The Houston Police Department has partnered with the Harris County Crisis Line, having a crisis worker housed in the public safety answering point who triages and manages many calls that would have previously been dispatched to uniformed officers.30 Lieutenant Brian … Mental Health Issues Discussion