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.

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.

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.

Community-Based Mental Health Crisis Response: An Overview of Models and Workforce Implications.

Communities across the United States are working to improve community-based mental health crisis response, with 1 goal being to reduce criminal legal system involvement among individuals with mental illnesses, behavioral disorders, or mental health crises. Existing and recently developed models can generally be divided into non-law enforcement-based response models and law enforcement-based response models. Wide variation exists in terms of staffing, how response teams are called out or dispatched, hours of operation and immediacy of response, and approaches to crisis resolution.

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.

Predictors of Criminal Sentiments Scale-Modified Scores in Outpatients with Legal System Involvement.

The Criminal Sentiments Scale-Modified (CSS-M) has been widely used as a measure of criminal attitudes. This analysis examined CSS-M scores in a large sample of outpatients with serious mental illnesses and a criminal legal system history. We compared total and subscale scores in our sample to scores from two other previously published U.S. studies in which the CSS-M was used, and evaluated associations between total CSS-M score and nine variables (age, educational attainment, gender, race, marital status, employment status, diagnostic category, substance use disorder comorbidity, and adverse childhood experiences (ACE) score). Scores were higher than in two prior U.S. studies involving other types of samples. Independently significant predictors of higher CSS-M scores included being younger (P < .001), having a higher ACE score (P < .001), being male (P = 03), not identifying as White (P < 001), not having a psychotic disorder (P < 001), and having a comorbid substance use disorder (P = 002). Future research should test the hypothesis that these factors increase risk for arrest and that arrest events, and subsequent criminal legal system involvement, are characterized by negative experiences and perceptions of poor procedural justice, which in turn underpin the negative opinions referred to as "criminal sentiments" or criminal attitudes.

The role of stigma and uncertainty in moderating the effect of procedural justice on cooperation and resistance in police encounters with persons with mental illnesses.

Within social psychology, procedural justice theory has been used to understand variations in compliance with legal authorities such as police. Thus, it may help explain variation in cooperation and compliance in encounters between police officers and people with serious mental illness (SMI), which are often fraught with difficulty and risk. In this paper, we examine the extent to which perceptions of procedural justice among persons with SMI are associated with self-reported levels of cooperation and resistance in encounters with police. We also examine stigma and encounter type as potential moderators of the procedural justice effect. 154 persons with serious mental illness who reported a police contact within the past year were interviewed using the newly developed Police Contact Experience Survey (PCES), which includes questions about the characteristics of the contact, perceived procedural justice (PPJ) and degree of cooperation and resistance. Participants also completed the Link Perceived Devaluation and Discrimination Scale (PDS). Findings suggest that greater PPJ is associated with more cooperation and less resistance. The effect on cooperation, however, is moderated by both perceived stigma and the type of encounter. The direct effect of perceived stigma (PDS) on cooperation was unexpected, with higher perceived stigma associated with greater cooperation. Findings underline the importance of both procedurally just treatment in police interactions with vulnerable individuals and further efforts to reduce the stigma of mental illness.

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.

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.

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.

Intervening at the entry point: differences in how CIT trained and non-CIT trained officers describe responding to mental health-related calls.

In response to challenges officers face with mental health-related calls, police departments are implementing specialized response programs like Crisis Intervention Teams (CIT). CIT is gaining support for its promise to promote safe, respectful interactions with police and individuals with mental illnesses. This paper outlines the results of a qualitative study investigating the impact of CIT. We found difference in CIT and non-CIT officers' response tactics to mental health-related calls and assessments of danger. CIT officers described a broader understanding of exhibited behaviors and considered more options when deciding the outcomes of calls. Implications and directions for future research are discussed.

Effects of Severe Mental Illness Education on MSW Student Attitudes About Schizophrenia.

Social work students (n = 60) in a master's-level course on severe mental illness participated in a quasi-experimental study examining the degree to which increased knowledge about and contact with individuals with schizophrenia during the course would impact their attitudes toward people with the disorder. Results revealed significant improvement in student knowledge and general attitudes after the course, and indicated that increased knowledge about schizophrenia was only related to general attitudinal improvement when accompanied by increased personal social contact. Implications for education on severe mental illnesses, and value and attitude development in social work education are discussed.

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).

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.

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.

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.

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.

Outcomes of police contacts with persons with mental illness: the impact of CIT.

The Crisis intervention team model (CIT) is possibly the most well known and widely adopted model to improve police response to persons with mental illness. A primary goal of CIT programs is to divert individuals with mental illness from the criminal justice system to mental health services. In this paper we examine the effectiveness of fielding CIT trained and supported officers for influencing call outcomes using data from patrol officers (n = 112) in four Chicago Police districts. Results from regression analysis indicate that CIT certified officers directed a greater proportion of persons with mental illness to mental health services than their Non-CIT certified peers. CIT did not have an immediate effect on arrest. Moderator analysis indicates that CIT had its biggest effect on increasing direction to services and decreasing "contact only" among officers who have a positive view of mental health services and who know a person with mental illness in their personal life. Additional moderators of the CIT effect on call outcomes include level of resistance and the presence of a weapon. Findings from this study have important implications for policy, practice and future research.

Examining the meaning attached to mental illness and mental health services among justice system-involved youth and their parents.

A large percentage of youth involved in the juvenile justice system experience mental health problems, yet many do not receive mental health care. In this study, we used a process-focused framework of mental health decision making to gain insight into the use of mental health services among these youth. In-depth interviews were conducted with nine youth and nine parents participating in a program servicing youth with mental health problems who have been in detention. Themes related to problem recognition, the decision to seek and participate in services, subjective norms, and juvenile justice system involvement emerged. Most families acknowledged their youth was having problems, but few defined those problems in mental health terms. This did not prevent them from seeking services, although some were not able to access adequate services until the justice system became involved. Participants were aware of negative attitudes about mental illness, and might have limited their social networks to shield themselves.