Center for Crisis Response and Behavioral Health: Research Hub

Title

Police Response Models for Handling Encounters with People Suffering from Mental Illnesses: a Survey of Police Chiefs

Citation

Seo, C., Kim, B. & Kruis, N.E. Police Response Models for Handling Encounters with People Suffering from Mental Illnesses: a Survey of Police Chiefs. Am J Crim Just 46, 793–814 (2021). https://doi.org/10.1007/s12103-020-09577-7

Summary

Current research

No previous research looks at chiefs’ perceptions of Police Response Models (PRM)
“Research indicates that the views of police chiefs strongly influence the adoption and implementation of any reform initiative, and subsequently, the achievement of significant organizational-level change” (pg. 4)
Sample of 190 police chiefs via surveys

Three research questions

To what extent do police chiefs favor each type of PRM (i.e. Crisis Intervention Training (CIT), co-response models, andother models with reduced training hours (OMRTH))?
Is there a group mean difference in chiefs’ perceptions of PRMs between police chiefs working in departments that operate a PRM and chiefs working in departments that do not operate a PRM?
What variables are related to chiefs’ favorability toward each PRM?

Results

Departments with PRM vs those without
About half of the chiefs did not have a PRM active in their department
Those who did have a PRM in place favored the CIT model and co-response model
- Crisis Intervention Training (CIT)
  - CIT model was preferred by higher-educated chiefs
  - CIT model was preferred in rural areas
  - “...as chiefs’ perceptions of multi-agency partnerships became more favorable, so too did their attitudes toward the CIT model” (pg. 11)
- Co-response produced similar results
  - “...statistical significance of having a master’s degree, working in an urban area, and multi-agency partnerships were related to chiefs’ favorability toward co-response models” (pg. 11)
  - Other models with reduced training hours (OMRTH)
  - Relationship between chief favorability and having a BA degree, a MA degree, and working in an urban area
- Department Characteristics
  - “...police chiefs working in departments that had a policy mandating officers to conduct follow-up visits for encounters with persons with mental illness reported less favorable attitudes toward the CIT model… but more favorable attitudes toward co-response models” (pg. 15)

Title

Variation across police response models for handling encounters with people with mental illnesses: A systematic review and meta-analysis

Citation

Chunghyeon Seo, Bitna Kim, Nathan E. Kruis, Variation across police response models for handling encounters with people with mental illnesses: A systematic review and meta-analysis, Journal of Criminal Justice, Volume 72, 2021, 101752, ISSN 0047-2352, https://doi.org/10.1016/j.jcrimjus.2020.101752

Summary

The effect sizes of all police response models for handling the mentally ill were small to substantial
Co-response models showed the largest effect size, followed by the CIT model and other models with reduced training hours
The effects of police response models were different depending on the outcome measures considered
Police response models showed little effect on “observed” outcome measures
The article sought to review and assess outcomes of police response models (PRMs)
3 main types of PRMs
Crisis Intervention Training (CIT)
Co-Response model
Other models with reduced training hours
The review found that the main three types of PRMs were effective in performing improving “self-reported changes in officer perception” or “self-reported changes in PWMI (persons with mental illness) perception” outcomes
PRMs had little effect on “observed officer behavior” outcomes, such as reduced arrests and excessive use of force
The review concluded that “PRMs offer a moderately effective solution for processing incidents with PWMI, although the effects of PRMs are different depending on the model implemented and the outcome measures considered.”
True effects of the existing PRMs on various outcomes of police encounters with PWMI are still unknown
Taheri (2016) sought to examine the effect CIT had on police use-of-force on PWMIs.
Results showed that officers who received the CIT training were less likely to arrest PWMIs, but the mean effect size (d) was 0.180.
Results also showed that CIT-trained officers were more likely to use police force on PWMIs (d=-0.301). Taheri assumes this is due to the small number of studies included in the analysis.
The current study found different results; a positive moderate effect on 9 ‘self-reported officer perception’ outcomes and a small effect on 5 ‘observed behavior outcomes’. Different results may be due to a difference in outcome measures (Taheri synthesized 2 outcome measures, this study synthesized 14)
Systematic review for this study included:
15 online databases
Google Scholar
References found in the initial sampling process were reviewed to see there were other relevant studies
The random-effects model used for all analyses to estimate the mean effect size in the dispersion of effects and make an inference to a larger population.

“Our findings indicate that collaborations between mental health professionals and law enforcement officers in co-response models may be more effective in handling police encounters with the mentally ill than providing training to frontline officers. As such, results suggest that policymakers should make efforts to increase funding, or redirect funding, to help more departments establish partnerships needed to incorporate co-response models” (pg.11)

Title

A systematic review of co-responder models of police mental health ‘street’ triage

Citation

Puntis, S., Perfect, D., Kirubarajan, A. et al. A systematic review of co-responder models of police mental health ‘street’ triage. BMC Psychiatry 18, 256 (2018). https://doi.org/10.1186/s12888-018-1836-2

Summary

Abstract

Review of street triage interventions with 3 aims:
Identify papers reporting on models of co-response police mental health street triage
Identify the characteristics of service users who come in to contact with these triage services
Evaluate the effectiveness of co-response triage services

Methods

Reviewed several databases and websites
No consistent terminology for police mental health triage
They found that there were no randomized controlled trials of street triage

Results

19 different triage models represented in the 26 eligible articles they found
12 used a ride-along method
5 used a combination of ride-along and control room support (MH professionals assisted officers via phone)
4 of these 5 mainly used control room support, only using ride-alongs for extreme situations
2 used telephone triage response
Of the 19, 12 operated 7 days a week
Only telephone models operated 24/7
3 models operated less than 7 days per week
Hours varied greatly, but most were scheduled to cover evenings and nights
Previous mental service use
51% of all referrals to the Cleveland Police Street Triage service were known to the local mental health team whilst 19% were currently on the caseload of a mental health service
48% of those who received an intervention from the Police Ambulance Crisis Response (PACER) team in Melbourne
78% of service users seen by a Los Angeles triage team had a history of psychiatric hospitalization
44-65% of people in Jenkins and colleagues’ study had had contact with a community mental health team within the past 2 weeks
Co-response team involvement
Two studies cited the most common reason triage was involved
Suicidal behavior
“Bizarre or disorganized” behavior
Four studies reported on repeat referrals
1: 12% of triage service users had a subsequent referral over an 18-month period
2: 13% over 3 months
3: 20% over 36 months
4: 29.9% over 12 months
Effectiveness of co-response model
Reduction in police detentions
All found that the co-response model decreased the number of service users made subject to S136 (involuntary commitment)
Face-to-face model was more effective than control room model
Significant reduction in mental health detentions in custody
Reduction in psychiatric hospitalization
Reduction in the proportion of police incidents resulting in psychiatric hospitalization in three studies
One study found an overall reduction in hospitalization due to fewer police detentions
Perception of service users
Reportedly felt criminalized in the past (non co-response model)
Felt less stigmatized, better de-escalation, and less threatening (co-response model)
Perception of providers
Providers found it helpful
Felt there was better communication between police, mental health services, and emergency departments
Improved speed and clarity of pathways to treatment for those seen by the triage teams
Cost
The average cost per crisis response was calculated to be 23% lower with the introduction of the triage program

Title

The effect of the COVID-19 pandemic on mental health calls for police service

Citation

Koziarski, J. The effect of the COVID-19 pandemic on mental health calls for police service. Crime Sci 10, 22 (2021). https://doi.org/10.1186/s40163-021-00157-6

Summary

Methods

Data
Obtained from the computer-aided dispatch system from Barrie Police Service (Barrie, Ontario, Canada)
January 1, 2014 through December 31, 2020
Mental health N=3977

Results

March 2020 - July 2020
No difference between the observed number of persons with perceived mental illness (PwPMI) calls and what would have been expected had the COVID-19 pandemic not occurred
August 2020
The observed number of PwPMI calls began a sustained positive increase away from what was predicted by the Bayesian Structural Time Series (BSTS) model
October 2020
22% increase in PwPMI calls relative to what was expected
The study found that the COVID-19 pandemic has influenced PwPMI calls for police service, but that the effect was not immediate

Title

Barriers and facilitators to implementing an urban co-responding police-mental health team

Citation

Bailey, K., Paquet, S.R., Ray, B.R. et al. Barriers and facilitators to implementing an urban co-responding police-mental health team. Health Justice 6, 21 (2018). https://doi.org/10.1186/s40352-018-0079-0

Summary

Methods

Mobile Crisis Assistance Team (MCAT) pilot program
A co-responding police-mental health team model with the addition of a medical professional
Qualitative data from two sources:
Focus group with MCAT members
One-on-one semi-structured interviews with key stakeholders
Focus groups
Two groups of six MCAT members each (N=12)
About 2 hours long each
Goal was to understand frontline staff perspectives on implementation
One-on-one interviews with stakeholders
About 1 hour long each
Focused on program development and implementation

Results

MCAT members were able to make referrals on the front end, but there was concern that they would not be able to follow-through on the back end
Not enough beds, not enough mental health professionals
MCAT members didn’t like wearing different uniforms and not being easily identified as police officers
Different uniforms were intentionally selected for the MCAT uniform to differentiate them from traditional police officers
MCAT members felt they weren’t integrated into the department/community well
No one knew their mission
MCAT members felt they could more easily work with other agencies and better understood their missions

Title

Crisis averted: How consumers experienced a police and clinical early response (PACER) unit responding to a mental health crisis

Citation

Evangelista, E., Lee, S., Gallagher, A., Peterson, V., James, J., Warren, N., Henderson, K., Keppich-Arnold, S., Cornelius, L., & Deveny, E. (2016). Crisis averted: How consumers experienced a police and clinical early response (PACER) unit responding to a mental health crisis. International journal of mental health nursing, 25(4), 367–376. https://doi.org/10.1111/inm.12218

Summary

Methods

12 consumers
All had contact with Alfred Police and Clinical Early Response (A-PACER)
Were assessed by an A-PACER clinician as being sufficiently well to provide written and informed consent.
Semi-structured interview
Questions were around their knowledge or A-PACER, their experience with the team, and recommendations they would make.

Results

Reasons for A-PACER contact
4 main reasons the team was called
Welfare check
Self-harm or intoxication
Threat to others
Psychotic episode
Outcome of A-PACER contact
Varying outcomes
2 transported to ED
3 admitted to hospital’s psychiatric unit
6 had no further intervention beyond A-PACER
What worked well
Communication
Consumers felt their needs were being considered
Clinicians were effective at de-escalating
Persistence of A-PACER team
Many consumers mentioned resisting the team, but being grateful for them in hindsight
Quick response
They were quick to arrive
Team was quick at building rapport in a short amount of time and under pressure
Handover of Information
Efficient handoff between A-PACER team and ED/psychiatric staff, case managers, psychologist or community services
Preferred outcome
A-PACER helped consumers achieve a preferred outcome
Not going to jail, being arrested. Allowed them to stay home.
Comparing A-PACER to other response models
Police-only response

Consumers reported that this led to a transfer straight to ED or a charge
Consumers reported an unpleasant experience with force and physical restraint

CAT model
- Similar response from the mental health provider, but A-PACER team was more responsive
- Lag in response time from CAT
Areas of Improvement
- Reduce public scrutiny
  - Consumers felt it was too visible/embarrassing
  - Requested that A-PACER use an unmarked car, police in plain clothes, and transportation to ED be made in an ambulance rather than a police van
- Further training
  - Police needed further training on mental health so they didn’t need to use force
- Follow-up and Communication
  - Some consumers spoke about “outsmarting” the MH providers and answering the questions the way they needed to get out of recommended treatment
  - Follow-up with usual mental health provider would be beneficial

Title

Improving police responses to suicide-related emergencies: New evidence on the effectiveness of co-response police-mental health programs

Citation

Blais, E., & Brisebois, D. (2021). Improving police responses to suicide‐related emergencies: New evidence on the effectiveness of CO‐Response police‐mental health programs. Suicide and Life-Threatening Behavior, 51(6), 1095–1105. https://doi.org/10.1111/sltb.12792

Summary

The article looks at the effectiveness of co-response models responding to mental health-related calls as opposed to crisis intervention teams
Limitations to the co-response model
- Not enough evaluations on the effectiveness have been done
- Potential threats to internal validity
- Some question the universal aspect of special police programs
Suicide-related emergency calls are a challenging problem that monopolizes a great deal of police resources
The objective of the study was to evaluate the impact of a co-response police-mental health program aimed at improving police interventions with individuals showing suicide-related behaviors on six outcomes
- Police use of force
- Arrests
- Transports to hospital against the will of the person
- Voluntary transports to hospital
- Referrals to community resources
- Management by social network
Risk of arrest was not affected by the co-response program
The co-response program was effective in decreasing police use of force
The co-response program of the Laval Police Department was associated with significant increases in referrals to community services and management of cases by social network

Title

Examining implementation of mobile, police-mental health crisis intervention teams in a large urban center

Citation

Maritt Kirst, Katherine Francombe Pridham, Renira Narrandes, Flora Matheson, Linda Young, Kristina Niedra & Vicky Stergiopoulos (2015) Examining implementation of mobile, police-mental health crisis intervention teams in a large urban center, Journal of Mental Health, 24:6, 369-374, https://doi.org/10.3109/09638237.2015.1036970

Summary

Abstract

Goal of study was to understand how to implement a multi-site Mobile Crisis Intervention Team (MCIT) in a large urban area, determining strengths and challenges, and examine satisfaction.

Methods

57 stakeholders at health system, community, managerial, team, and consumer levels
Data collected through interviews and focus groups

Results/Strengths

Program satisfaction
- Health system, program, and community stakeholder perceptions
- Mostly positive
- Believed it helped with crisis response, diversion away from hospitals/criminal justice system, and made officers more available for their work
- Differing opinions on mandate
  - Some believed mental health professionals should be first responders (current MCIT program has them as second responders)
  - Some believed officers would treat the mental professionals as a cure-all and let them take over
- Consumer Perceptions
  - Consumers felt listened to and respected
- Consumers felt they were given options rather than told what to do
  - Made them feel safer, supported, and understood that they were experiencing crisis rather than labeled “criminal”
    - Some consumers still felt they were not given a choice
  - Confusion about identity of the MCIT
    - Uniforms were similar to officers’ uniforms
  - Multiple cultures and positive partnerships
  - Collaborative consumer engagement
    - Team had to work together to decide who was best fit to handle situations
  - Challenges
    - Difference in goals between law enforcement and health care
    - Lack of awareness of MCIT mandate, causing low team utilization
    - Limited training: nurses and officers felt they had little knowledge about each other’s profession/professional culture
    - Lack of role clarity
      - Cars
        
        Some participants viewed marked police cars as helpful in identifying the team and assisting in quick response times
        
        Others argued the cars could be stigmatizing and physically uncomfortable for consumers
      - Uniforms
        
        Some participants thought that uniformed MCIT police officers serve to clearly distinguish officer and nurse roles and indicated their association with the police
        
        Some viewed uniforms as intimidating for consumers, preferring officers be dressed in plain clothes
        
        Hard to identify the nurses from the officers
      - Transfer of program consumers
        
        Long waits in emergency departments
      - Lack of coordinated mental health systems
      - Need for more effective program partnership, appropriate consumer referral, and individual care
      - Consumers wanted more effective case management

Title

Police Response to People with Mental Illnesses in a Major U.S. City: The Boston Experience with the Co-Responder Model

Citation

Morabito, M. S., Savage, J., Sneider, L., & Wallace, K. (2018). Police response to people with mental illnesses in a major U.S. city: The Boston experience with the co-responder model. Victims & Offenders, 13(8), 1093–1105. https://doi.org/10.1080/15564886.2018.1514340

Summary

Review of Literature

Strengths
- Literature suggests the co-response model is a promising practice in need of additional study
- Additional research supports the finding that the co-responder program may enhance the relationships between police and community members
- Co-responder programs may decrease injuries, increase escorts to hospitals and treatments, decrease involuntary commitment, and decrease the time officers spend at the hospital when compared with officers responding alone
- Results are dependent on having a good and accessible mental health partner
Weaknesses
- Difficult defining roles and adjusting to job cultures of a different profession
- Lack of clarity on who should take the lead

Boston Model

Before 2011, one of three outcomes were likely in Boston
- Referring to Boston EMS for transport to ER (costly and not always helpful)
- Informal response (doesn’t address underlying mental illness)
- Formal response (arrest)
As of 2018
- 4 master’s-level clinicians on staff
- Attend calls with officers in marked cars
- Also have on-call clinicians
Implementation Challenges
- Funding
  - Not consistent
  - Relying solely on state and federal grant
- Clinician “fit”
  - Hard to find clinicians with the right skillset and temperament to work in the police culture
- Officer buy-in
  - Officers are naturally suspicious of outsiders
  - Crucial to have officer input during the hiring process
- Defining roles
  - EMS, police, and clinicians needs to be on the same page about who is doing what
  - Dispatch needs to be trained to identify when a co-response team should be sent
- Computer automated dispatch (CAD) system
  - Not able to identify calls with mental illness

Findings

Overview of the data
- In 2010 (before the co-responder model), police referred 25 people to Boston Emergency Services Team (BEST)
- In 2017 (after the co-responder model was implemented), 509 people were referred to BEST
Officer perception of efficacy of co-responder model
- Felt they could quickly help someone in crisis
- Felt clinicians helped with de-escalation
- Officers were worried that clinician’s safety was at risk
- Officers felt there was a lack of resources and funding

Title

Effectiveness of Police Crisis Intervention Training Programs

Citation

Rogers, M. S., McNiel, D. E., & Binder, R. L. (2019). Effectiveness of Police Crisis Intervention Training Programs. Journal of the American Academy of Psychiatry and the Law Online. https://jaapl.org/content/early/2019/09/24/JAAPL.003863-19

Summary

Most of the studies on CIT involve analysis of the planning, deployment, and procedural functioning of the CIT process itself, including the selection, training, operations, and measurement or self-report of CIT-trained officers.
There have been concerns regarding the possibility that a jail diversion program such as CIT may shift cost burdens from police budgets (generally relatively politically favored) to community mental health budgets (potentially less relatively politically favored).
Much research has shown an improvement in attitudes and a reduction of stigma in police officers who received mental health training.
Evidence for benefits at officer-level
- Officer satisfaction
- Self-perception of reduction in the use of force
There is also evidence for CIT’s effect on pre-booking jail diversion.
- One study said that the highest situations were often elevated to were verbal negotiation
CIT was assessed to be the best program in terms of reducing re-offending and improving mental health outcomes.
Despite a lack of evidence for effectiveness in terms of its original goal of reducing lethality during police encounters with people with mental health and substance use disorders, CIT has been shown to have some measurable positive effects, mainly in officer-level outcomes.
CIT may influence the prevalence and frequency of early-stage, outpatient psychiatric referrals.

Center for Crisis Response and Behavioral Health: Research Hub