Making Decisions About Calling 988 Versus 911: Understanding End-User Views Before the Launch of 988.

OBJECTIVE: The 988 telephone number was implemented in July 2022 as an easily accessible way to reach the National Suicide Prevention Lifeline and has been envisioned as one step in building a more robust crisis care continuum in the United States. This study aimed to describe how various stakeholders anticipated using 988 compared with the most widely known crisis line: 911. METHODS: Focus groups (N=15, with 76 total participants) were conducted in three counties in New York State between October and November 2021, before the launch of 988. Five stakeholder groups were included: mental health services consumers, family members of consumers, community members, mental health providers, and crisis call takers. Thematic analysis was used to code and analyze all focus group transcripts. RESULTS: Participants anticipated that key uses for 988 would be accessing support during a crisis, obtaining connections to local resources and services, and receiving alternatives to law enforcement response. However, participants continued to articulate uses for 911 during a mental health crisis, especially for situations involving "safety concerns." CONCLUSIONS: The broad expectations for 988 suggest that the line must be flexible and responsive to a range of needs and that communities should clearly define what is available through 988. More implementation research is needed to ensure a detailed understanding of those whom 988 is serving, how the line meets callers' needs, and the line's potential for connecting people to needed services.

Contexts shaping misdemeanor system interventions among people with mental illnesses: qualitative findings from a multi-site system mapping exercise.

BACKGROUND: People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses. METHODS: System mapping exercises were conducted with misdemeanor system stakeholders from the jurisdictions of Atlanta, Chicago, Manhattan, and Philadelphia. Narrative detail on decision-making and case processing, both generally and in relation to specific types of behavior, including trespassing, retail theft/shoplifting, and simple assault, were coded and analyzed for thematic patterns. Based on the qualitative analysis, this paper offers a conceptual diagram of contexts shaping misdemeanor system interventions among people with mental illnesses. RESULTS: All four sites have been engaged in efforts to reduce the use of misdemeanor charges both generally and in relation to people with mental illnesses. Decision-makers across all sites experience contexts that shape how, when, and where they intervene, which are: (1) law and policy environments; (2) location of the behavior; (3) expectations of stakeholders; (4) knowledge of mental illnesses; and (5) access to community resources. Law and policy environments expand or constrain opportunities for diversion. The location of offending is relevant to who has a stake in the behavior, and what demands they have. Clinical, experiential, and system-level knowledge of mental illnesses inform a chain of decisions about what to do. The capacity to address mental health needs is contingent on access to social services, including housing. CONCLUSION: People making decisions along the criminal legal continuum are critical to illuminating the dynamic, inter-related contexts that facilitate and frustrate attempts to address defendants' mental health needs while balancing considerations of public safety. Multi-sector, scenario-based or case study exercises could help identify concrete ways of improving each of the contexts that surround whole-of-system decisions.

Changes in knowledge, behavioural expectations, self-efficacy, and stigma after an educational campaign about early psychosis for jail correction officers.

AIM: Given a lack of interventions to identify and engage individuals with early psychosis in jail and connect them to specialty care in the community upon release, we designed a Targeted Educational Campaign (TEC) for correction officers working in jails. We report on impacts of the TEC on officers' cognitive and attitudinal outcomes. METHODS: Three different cohorts of officers-totaling n = 451-took part in a survey: 200 at baseline before the TEC began, 123 at 6-months into the TEC, and 128 at 12-months into the TEC. Among each cohort of officers, four constructs were measured: (1) knowledge about early psychosis; (2) self-efficacy around detecting early psychosis and referring to mental health services within the jail; (3) expectations about the benefits of detection and referral to specialty care; and (4) social distance stigma toward detainees with early psychosis. RESULTS: While exposure to TEC elements was as-planned in the first 6-months, exposure diminished substantially at 12-months, coinciding with increasing fatigue among correction officers due to the COVID-19 pandemic as well as serious staffing shortages. Knowledge, behavioural expectations, and self-efficacy scores improved from baseline to 6-months, with greater exposure to roll-call messages driving scores. Knowledge and behavioural expectations at 12-months were associated with having received an information post card. Social distance stigma worsened across timepoints. CONCLUSIONS: An educational campaign for jail staff can enhance knowledge, self-efficacy, and behavioural expectations regarding early psychosis, though only while the campaign elements are active. Further research should investigate whether or not social distance stigma or other types of stigma increase alongside improvements.

Competing Concerns in Efforts to Reduce Criminal Legal Contact Among People with Serious Mental Illnesses: Findings from a Multi-City Study on Misdemeanor Arrests.

People with serious mental illnesses are disproportionately involved in the criminal legal system, often for low-level, non-violent misdemeanors. This paper examines how decision-makers at different stages of the criminal legal system articulate unique visions of the "best approach" for addressing this problem of over-representation. Focus groups and in-depth interviews were conducted with 94 stakeholders from Atlanta, Chicago, New York City, and Philadelphia to understand how decision-makers from different agencies use and process specific misdemeanor charges in relation to people with serious mental illnesses. Data were analyzed using a thematic approach. The data reveal a series of tensions regarding how criminal legal system stakeholders process people with serious mental illnesses through the misdemeanor system. Three key themes emerged from analysis. The first characterizes the shared commitment across agencies to reducing system contact among people with mental illnesses. The second explores how agencies differ on how to make good on that commitment because of the distinct values and goals they bring to the table. The final theme explores the limits of current approaches to reducing system contact for people with mental illnesses. Findings are discussed in the context of literature on "loose coupling" and the focal concerns framework and demonstrate that decisions about how and when to intervene with people with mental illnesses in the criminal legal system are influenced by the varying orientations, goals, and values of stakeholder agencies. Understanding these core differences is a critical step toward value alignment in strategies to reduce system involvement among people with mental illnesses.

Misdemeanor Charges Among Individuals With Serious Mental Illnesses: A Statewide Analysis of More Than Two Million Arrests.

OBJECTIVE: Reducing the overrepresentation of individuals with serious mental illnesses in the criminal legal system requires a better understanding of the charges for which they are most commonly arrested. This study aimed to compare violent offenses, penal code classifications, Uniform Crime Reporting (UCR) codes, and specific charges in arrests among individuals with and individuals without serious mental illnesses. METHODS: The authors analyzed all arrests (N=2,224,847) in New York State during 2010-2013. Medicaid data and the state mental health authority's records were used to create an indicator of serious mental illness for each arrest. RESULTS: Among arrests involving individuals with the serious mental illness indicator (N=91,363), 7.3% were for violent offenses, compared with 7.6% of arrests involving individuals without the indicator. Among 10 penal code classifications, class B felonies and class A misdemeanors were more likely in arrests among those with the indicator than among those without it. Of the 14 UCR codes examined, seven were more common in arrests with the serious mental illness indicator. Criminal trespass was among the most common charges in arrests involving individuals with the indicator. CONCLUSIONS: Most arrests involving people with serious mental illnesses were for misdemeanors, specifically class A misdemeanors, and this class comprised a larger proportion of arrests for those with the indicator than of arrests for those without it. New approaches are needed to address the situations-usually related to socioeconomic disadvantage-that result in individuals with mental illnesses receiving misdemeanor charges and cycling through the criminal legal system.

Modeling the effects of Crisis Intervention Team (CIT) training for police officers: How knowledge, attitudes, and self-efficacy drive de-escalation skills and referral decisions.

OBJECTIVE: Prior research on Crisis Intervention Team (CIT) training for police officers has demonstrated improvements in knowledge, attitudes, self-efficacy, and stigma, but how these factors work together to influence behavioral outcomes like de-escalation skills and referral decisions remains unstudied. METHOD: 251 CIT-trained and 335 non-CIT officers completed in-depth surveys measuring these six constructs. We used structural equation modeling to test fit of the data to our hypothesized model and made indicated changes to improve fit. RESULTS: An alternate 8-path model (with three paths originally hypothesized being removed) fit reasonably well, and allowing path coefficients to differ for CIT and non-CIT groups resulted in models with similar fit statistics. CONCLUSION: CIT training enhances knowledge and attitudes, both of which have beneficial effects on stigma. Though an important outcome itself, lower stigma does not have an effect on de-escalation skills and referral decisions, though self-efficacy clearly does.

Characterizing Arrests and Charges Among Individuals With Serious Mental Illnesses in Public-Sector Treatment Settings.

Objective: Individuals with serious mental illnesses are overrepresented in all facets of the legal system. State-level criminal histories of patients with serious mental illnesses were analyzed to determine the proportion who had been arrested and number of lifetime arrests and charges, associations of six variables with number of arrests, and the most common charges from individuals' first two arrests and most recent two arrests. Methods: A total of 240 patients were recruited at three inpatient psychiatric facilities and gave consent to access their criminal history. Information was extracted from Record of Arrest and Prosecution (RAP) sheets for lifetime arrests in Georgia. Results: A total of 171 (71%) had been arrested. Their mean±SD lifetime arrests were 8.6±10.1, and mean lifetime charges were 12.6±14.6. In a Poisson regression, number of arrests was associated with lower educational attainment, Black or African American race, the presence of a substance use disorder, the presence of a mood disorder, and female sex. Common early charges included marijuana possession, driving under the influence of alcohol, and burglary and shoplifting. Common recent charges included probation violations, failure to appear in court, officer obstruction­related charges, and disorderly conduct. Conclusions: Findings point to a need for policy and program development in the legal system (e.g., pertaining to charges such as willful obstruction of an officer), the mental health community (e.g., to ensure that professionals know about clients' legal involvement and can partner in strategies to reduce arrests), and social services sectors (to address charges, such as shoplifting, often related to material disadvantage).

Using the Theory of Planned Behavior to Understand How Crisis Intervention Team (CIT) Training Facilitates Police Officers' Mental Health Referrals.

The Theory of Planned Behavior posits that behaviors are predicted by one's intention to perform them; intention is driven by attitude toward the behavior, subjective norm, and perceived behavioral control. We used this theory to predict Crisis Intervention Team (CIT)-trained and non-CIT officers' intention to facilitate referral of persons with suspected mental illnesses to mental health services. CIT-trained (n = 251) and non-CIT (n = 335) officers from six law enforcement agencies participated. CIT-trained officers had significantly greater scores on all constructs. Theory constructs fit the data well, and fit did not differ meaningfully between the two groups. Direct and indirect predictors together accounted for 28% and 21%, respectively, of variance in behavioral intention. Attitude was the strongest predictor. Intentions to facilitate mental health referrals may be driven by the same factors among CIT-trained and non-CIT officers, but CIT officers, even at a median of 22 months after training, have significantly higher scores on those factors.

The Impact of Crisis Intervention Team Response, Dispatch Coding, and Location on the Outcomes of Police Encounters with Individuals with Mental Illnesses in Chicago.

The Crisis Intervention Team (CIT) model has been implemented in over 3,000 communities across the USA. Research to date has shown beneficial results in terms of officers' knowledge, attitudes, self-efficacy, stigma, and force preferences. This study aimed to broaden the lens on the implementation context of CIT to examine whether factors in the environment and response process affect how calls are resolved. This study focused on several factors-CIT response, call location, and upstream decisions to pre-identify calls as mental health-related-that may impact call outcomes. Our findings suggest that CIT response, dispatch coding, and the places where calls originate play a role in shaping outcomes. More research is needed to unpack the effects of this wider CIT implementation environment.

Police Reform From the Perspective of Mental Health Services and Professionals: Our Role in Social Change.

Calls to defund and reform police agencies have been emphasized in recent public discourse. Demands range from shuttering police agencies to shifting resources and responsibility for responding to noncriminal social and behavioral health vulnerabilities to the health and social services sector. This Open Forum discusses how police officers became primary responders to behavioral health concerns, how this arrangement disproportionately and negatively affects communities of color, and several solutions to these circumstances. The mental health field must advocate for the policies and resources needed to address urgent mental health needs and crisis response. Several conditions for successful outcomes that do not further compound racial inequities are discussed.

What can we expect of police in the face of deficient mental health systems? Qualitative insights from Chicago police officers.

WHAT IS KNOWN ON THE SUBJECT?: People with serious mental illnesses are overrepresented in the criminal justice system. Interventions such as Crisis Intervention Teams and Co-responder Teams may improve police officers' ability to provide effective response. There is still a gap in our knowledge of the nature of the situations officers are responding to and their perceptions of what is needed for effective response. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides insight into officer perceptions and experiences of the mental health-related calls they respond to involving youth, adults and families. Officers often refer to people in crisis as having "gone off meds" but also recognize more complex factors at the individual level (e.g., co-occurring issues), family level (challenges of caring for a loved one with mental illness) and community level (deficiencies in health and social resources to address long-term unmet needs). Deficiencies in the resources needed to address the unmet needs of people and their families frustrate officers' desires to make a difference and effect long-term outcomes. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings underscore the need for cities and communities to develop alternatives to emergency departments which, in the long term, may provide the best hope for reducing the reliance on police as mental health interventionists. Formal collaborations between the law enforcement community and the mental health nursing community could be focused towards this end. Findings provoke the larger question of what should "count" as good police work in the face of deficient community health systems. Practitioners should consider the distinction between police effectiveness and "whole system" effectiveness. Police officers could be held to account for "principled encounters" that are resolved in ways that reduce immediate harm, avoid stigma and advance procedural justice, but the full impact of their effects is contingent on the capacity of the wider system to do its job. Mental health nurses are well positioned to assist with officer training and provide support to officers responding to mental health-related situations. ABSTRACT: Introduction Data on fatal outcomes of police encounters, combined with evidence on the criminalization of people with mental illnesses, reveal a grave need to improve outcomes for individuals with mental illnesses who come into contact with police. Current efforts are hampered by a lack of in-depth knowledge about the nature of nature and context of these encounters. Aim/Question Building on previous findings from a larger study on the nature and outcomes of mental health-related encounters with police in Chicago, this paper examines officer perspectives on the unmet needs of individuals and their families and the ways in which the mental health and social system environment constrain officers' abilities to be responsive to them. Methods Findings are drawn from qualitative data produced through 36 "ride-alongs" with police officers. Field researchers conducted open-ended observations of police work during routine shifts and carried out interviews with officers-according to a ride-along question guide-during periods of inactivity or between calls for service to ask about experiences of mental health-related calls. Field notes describing their observations and ride-along interviews were analysed inductively using a combination of open and focused coding. Results Officers responded to a variety of mental health-related calls revealing complex, unmet needs at individual and family levels. A common theme related to officers' perceptions that "going off meds," combined with other situational factors, resulted in police being involved in behavioural health situations. The data also revealed broader aspects of the health and social system that, in officers' minds, constrain their ability to effect positive outcomes for people and their families, especially in the long term. Discussion Findings beg the larger question of what it is we, as a society, should expect of police in the handling of mental health-related calls, given their concerns with the wider health and social service system that they experience as deficient. At the same time, the view that "going off meds" is a common trigger of mental health-related events should be interpreted with care, as it may signal or perhaps serve as a shorthand for more complex health and social needs that could be obscured by a pharmacological or medicalized perspective on mental illness. This is an important area of future inquiry for research at the intersection of policing and mental health nursing. Implications for practice The contribution of police to the wellness and recovery of people and their families is constrained by the ability of the community health and social service system to do its job. A wave of new initiatives designed to enhance the interface between police and the medical community holds out hope for alleviating officers' concerns about whether they can work in tandem with the rest of the system to make a difference. For now, we suggest that what we can expect of police is to implement "principled encounters" that ensure public safety while achieving harm reduction, self-determination and the reduction of stigma. Mental health nurses are well positioned to assist with officer training and provide support to officers responding to mental health-related situations. However, the fields of policing and nursing practice may not yet fully understand the individual, family and community dynamics driving calls for police service. The notion of "gone off meds" should be interrogated as a potential trope that obscures a whole-of-person approach and whole-system approach to mental health crisis response and care.

What Research on Crisis Intervention Teams Tells Us and What We Need to Ask.

Developed over 30 years ago, the Crisis Intervention Team model is arguably the most well-known approach to improve police response to individuals experiencing mental health crisis. In this article, we comment on Rogers and colleagues' review (in this issue) of the CIT research base and elaborate on the current state of the evidence. We argue that CIT can be considered evidence based for officer level outcomes and call level dispositions. We then discuss the challenges that currently make it difficult to draw conclusions related to arrest, use of force, and injury related outcomes. More research, including a randomized, controlled trial is clearly needed. But we caution against focusing narrowly on the training component of the model, as CIT is more than training. We encourage research that explores and tests the potential of CIT partnerships to develop effective strategies that improve the mental health system's ability to provide crisis response and thus reduce reliance on law enforcement to address this need.

Major Mental Illness as a Risk Factor for Incarceration.

OBJECTIVE: Individuals with serious mental illness are overrepresented in correctional populations. However, little is known about the representation of persons with serious mental illness at earlier stages in the criminal justice process. This research sought to measure the prevalence of arrestees in New York State who were treated for a major mental illness in the year before their arrest and to assess whether these individuals had a disproportionate rate of incarceration. METHODS: Approximately 600,000 individuals arrested in New York State between January 1, 2010, and December 31, 2013, were matched against public mental health records to identify defendants diagnosed as having a major mental illness in the 12 months before their arrest. RESULTS: Between 4% and 6% of the arrestees were diagnosed as having a major mental illness during a mental health service visit in the 12 months prior to their arrest. A major mental illness diagnosis was associated with more than a 50% increase in the odds of a jail sentence for misdemeanor arrestees, after the analyses controlled for the other case characteristics. Conversely, it was unrelated to the likelihood of a prison sentence given a felony arrest, but it did moderate the effect of other case characteristics within the group of arrestees with felonies. CONCLUSIONS: Differential adjudication of misdemeanor arrestees with a major mental illness diagnosis appears to contribute to their overrepresentation within the jail population. The role that poverty and pretrial incarceration may play in this relationship was not explored in this research and should be the subject of future investigation.

Improving police interventions during mental health-related encounters: Past, present and future.

There are calls across America for police to re-imagine themselves as "guardians" rather than "warriors" in the performance of their innumerable duties. The contentious history of police attitudes and practices surrounding encounters with people affected by mental illnesses can be understood through the lens of this wider push toward guardianship. At least as far back as the de-institutionalization of mental health care and the profound lack of community-based resources to fill service deficits, the role of police as mental health interventionists has been controversial and complex. This paper reviews the first wave of reform efforts designed to re-shape police sensibilities and practices in the handling of mental health-related encounters. We argue that such efforts, centred on specialized training and cooperative agreements with the health care sector, have advanced a guardian mindset through improved knowledge and attitudes about mental health vulnerabilities and needs. Building on the progress made, we suggest there are critical opportunities for a new wave of efforts that can further advance the guardianship agenda. We highlight three such opportunities: (1) Enhancing experiences of procedural justice during mental health-related encounters; (2) Building the evidence base through integrated data sets; and (3) Balancing a "case-based" focus with a "place-based" focus.

Everyday police work during mental health encounters: A study of call resolutions in Chicago and their implications for diversion.

In recent decades, there has been sustained focus on police responses to persons experiencing mental health crises. The Crisis Intervention Team (CIT) model has been a seminal effort to improve safety, reduce arrests and enhance the use of emergency psychiatric assessment. With CIT well established, new discussions have emerged around how to further enhance the police-public health interface, including diversion from hospital emergency departments. In this context, this article takes stock of current police practices, utilizing descriptive data on 428 mental health-related calls addressed by Chicago Police over 3 years triangulated with insights from 21 in-depth officer interviews. During these calls, hospital transports were conducted more often than arrests. Moreover, informal interventions - without any legal action or hospitalization - were used most often, speaking to the "gray zone" nature of mental health-related encounters. Taken together, the data reveal the need for non-crisis diversion options that address chronic vulnerabilities.

The crisis intervention team (CIT) model: An evidence-based policing practice?

As academic researchers, we are often asked to opine on whether the Crisis Intervention Team model (CIT) is an evidence-based practice (EBP) or evidence-based policing. Our answer is that it depends on how you define evidence-based practice and what outcome you are interested in. In this commentary, we briefly describe the CIT model, examine definitions of evidence-based practice and evidence-based policing, and then summarize the existing research on what is known about the effectiveness of CIT to date. We conclude that CIT can be designated an EBP for officer-level cognitive and attitudinal outcomes, but more research is needed to determine if CIT can be designated an EBP for other outcomes. Using an evidence-based practice process approach, CIT may also be a justified strategy for many communities. Future directions to inform the field are discussed.

The "Gray Zone" of Police Work During Mental Health Encounters: Findings from an Observational Study in Chicago.

Although improving police responses to mental health crises has received significant policy attention, most encounters between police and persons with mental illnesses do not involve major crimes or violence, nor do they rise to the level of requiring emergency apprehension. Here, we report on field observations of police officers handling mental health-related encounters in Chicago. Findings confirm that these encounters often occur in the "gray zone", where the problems at hand do not call for formal or legalistic interventions including arrest and emergency apprehension. In examining how police resolved such situations, we observed three core features of police work: (1) accepting temporary solutions to chronic vulnerability; (2) using local knowledge to guide decision-making; and (3) negotiating peace with complainants and call subjects. Study findings imply the need to advance field-based studies using systematic social observations of gray zone decision-making within and across distinct geographic and place-based contexts. Policy implications for supporting police interventions, including place-based enhancements of gray zone resources, are also discussed.

Surveys of Police Chiefs and Sheriffs and of Police Officers About CIT Programs.

OBJECTIVE: Two surveys were conducted on the crisis intervention team (CIT) model, a police-based program designed to improve responses to individuals with mental illnesses. METHODS: Data were collected between July and September 2013 from 171 police chiefs and sheriffs (42 had implemented CIT in their agency), and 353 law enforcement officers (273 had CIT training) in Georgia. RESULTS: Police chiefs and sheriffs reported barriers to implementing CIT, such as not having enough officers and insufficient access to mental health services. CIT-trained officers differed from non-CIT-trained officers only with regard to being less likely to use force in response to a man with psychotic agitation described in a vignette, when the analysis controlled for whether the officer carried an electronic control device. CONCLUSIONS: Some hypothesized differences, such as in job satisfaction and work burnout, were not observed. However, CIT-trained officers appeared to be less likely to revert to force in a situation involving psychotic agitation.

Understanding how police officers think about mental/emotional disturbance calls.

Police officers frequently respond to calls involving persons with mental illnesses and in doing so, they are key gatekeepers of access to mental health treatment as well as entry into the criminal justice system. Programs such as Crisis Intervention Teams (CIT) are being implemented across the United States and elsewhere to train officers to respond more effectively and facilitate access to mental health services when appropriate. These programs would benefit from a thorough understanding of these encounters from the perspective of police officers. We take as a premise that officers develop frames of reference or "schema" for understanding and responding to these encounters that are shaped by socialization, training, and their experience as police officers. In this study, we examine police officer schema of mental/emotional disturbance (M/EDP) calls. Qualitative interviews provided the foundation to develop the Needs on the Street Interview (NOSI) to tap officer schema of four types of M/EDP scenarios. The NOSI was administered to 147 officers in Chicago and Philadelphia. Latent Class Analysis (LCA) was conducted separately for each scenario to examine groups of officers with different schema as well as predictors of schema group. For three of the four scenarios, officers were classified into a two category or schema model, for the fourth (crime reported) a three category model was supported. Schema groups tended to be differentiated by ratings of level of resistance/threat and substance use. Contrary to our expectations, CIT and law enforcement experience did not predict officer schema group. While the CIT model emphasizes de-escalation skills to reduce resistance and the need for officers to use force, CIT and other training programs may want to consider increasing content related to factors such as co-occurring substance use and managing resistance.