Articles

Why Juvenile Detention Makes Teens Worse

Friday, Aug. 07, 2009

By Maia Szalavitz

Parents have always warned teenagers against falling in with the wrong crowd, those kids they consider bad influences. Now a new study of juvenile detention in Montreal adds to the evidence that Mom and Dad may have a point.

Researchers found that rather than rehabilitating young delinquents, juvenile detention — which lumps troubled kids in with other troubled kids — appeared to worsen their behavior problems. Compared with other kids with a similar history of bad behavior, those who entered the juvenile-justice system were nearly seven times more likely to be arrested for crimes as adults. Further, those who ended up being sentenced to juvenile prison were 37 times more likely to be arrested again as adults, compared with similarly misbehaved kids who were either not caught or not put into the system. (Read "Getting the Juvenile-Justice System to Grow Up.")

"It's much worse than we would have expected," says Richard Tremblay, a psychology professor at the University of Montreal and a co-author of the study, which was published in the Journal of Child Psychology and Psychiatry. "By having them live together, they form relationships. It's more likely to increase the problem."

The 20-year study followed 779 low-income youth in Montreal with annual interviews from age 10 to age 17, then tracked their arrest records in adulthood. Researchers also interviewed the teenagers' parents, schoolmates and teachers. The study accounted for variables such as family income, single-parent-home status and earlier behavior problems (such as hyperactivity) that are known to affect delinquency risk. (See pictures of crime in Middle America.)

Kids who entered the juvenile-justice system even briefly — for example, being sentenced to community service or other penance, with limited exposure to other troubled kids — were twice as likely to be arrested as adults, compared with kids with the same behavior problems who remained outside the system. Being put on probation, which involves more contact with misbehaving peers, in counseling groups or even in waiting rooms at probation offices, raised teens' odds of adult arrest by a factor of 14.

The rehabilitation of troubled teens has long been a contentious issue, pitting the individual needs of problem children and families against a system that does not typically give social workers adequate tools or resources to help. Often, the treatment of difficult or drug-using teens occurs en masse — in residential homes, for example — but instead of scaring kids straight, the group experience tends to glamorize delinquency and drug use. (Read "Teens Behaving Badly?")

Why? In any such setting, teens establish a predictable social hierarchy, says Tom Dishion, director of research at the Child and Family Center at the University of Oregon, who was not involved with the study. The kids who have behaved worse than others — committing robbery, for instance, vs. smoking cigarettes — earn the most credibility with their peer group, which encourages further bad behavior. "That story [about robbing someone] has a function of making that kid more interesting. He or she gets a lot of attention. [These kids] become higher in the social hierarchy."

Says Tremblay: "There is that competition of who is going to do the worst stuff — for them, it's the best stuff — like stealing the biggest or best car."

Past research has also shown that peer exposure can worsen behavior. In a 1995 study conducted by Dishion involving 158 high-risk families in Oregon, researchers compared the impact on teens' behavior of four interventions: parenting groups focused on effective discipline, social-skills-training groups for teens, both the parent- and teen-focused group interventions, or no group treatment at all. Overall, the parent-focused group was most effective, leading to reductions in teen smoking and misbehavior at school. The teen-focused group, by contrast, significantly increased participants' rate of aggressive behavior and smoking; in the combination group, kids showed no improvement, presumably because the exposure to other teens canceled out the positive effect of the parents.

The new study supports these findings, suggesting that family therapy or one-on-one counseling — or any intervention that doesn't aggregate troubled teens — is safer and more likely to be effective than group activities. But if groups must be used, experts say that high supervision and low child-to-staff ratios are essential to minimize the risk of behavior contagion.

"I think it's a very important finding, and it's consistent with other research in the last 10 years on this topic," says Dishion. "What's really surprising is that we don't have more research showing this to be true. Almost everyone you tell about these findings who has worked in [residential or juvenile-justice settings] is not surprised. I think there's a tacit agreement not to look too carefully."

Study: Mental health courts showing positive results

Please click on the following link to read/listen to the coverage:

http://minnesota.publicradio.org/display/web/2009/07/17/mental_health_courts/

by Elizabeth Stawicki, Minnesota Public Radio July 17, 2009

St. Paul, Minn. — A New York-based policy research group says Hennepin County's criminal mental health court is showing positive results.

Mental health courts are specialized courts that deal with people's underlying mental health problems as well as their crimes. The aim is to reduce repeat offenses and increase compliance with outpatient treatment and medication.

Minnesota's chief justice and the research group unveiled the findings Friday at the history center before an audience of judges, social workers, county commissioners and advocates.

Criminal mental health courts are relatively new; Hennepin County's began only six years ago. Today, there are about 250 of them around the U.S. They began in response to what the justice system began seeing was a revolving door for the mentally ill.

People suffering from illnesses such as schizophrenia and bipolar disorder would commit property crimes or assaults. Police would arrest them; a judge would sentence them; they would do their time and be released, only to start the cycle over again. Through treatment, medication and intense supervision, mental health courts try to end that cycle.

Because mental health courts are relatively new, there've been few studies on how well they work. Minnesota Chief Justice Eric Magnuson said evaluating the courts is as important as having them.

"We do what we think is right, but we need to find out if our assumptions are correct," Magnuson said. "Do we get the results that we hope to get? Here, the results are quite promising."

"Here, the results are quite promising." - Chief Justice Eric Magnuson

Through a MacArthur Foundation grant, New York-based Policy Research Associates studied four mental health courts in Hennepin County, San Francisco, San Jose, and Indianapolis. The research showed generally about a 20 to 25 percent improvement in the outcomes for offenders who went through mental health courts compared to those who did not.

For example, the research showed those who went through Hennepin County's mental health court were, on average, likely to get arrested again in four months. Those who did not go through the specialized court got arrested again in less than three weeks.

Sociologist Henry Steadman, who heads the New York-based policy research group, said it's important to view those numbers in context.

"Taking a hard-core, challenging population that has failed repeatedly in all three systems: criminal justice, substance abuse and mental health," Steadman said, "and has cycled and is a particularly challenging group, and have come up with an intervention that is a 20 to 25 percent improvement on almost all the measures. My evaluation is that's pretty damn good in today's world."

But at a time when county budgets are strapped for funding, mental health courts don't show an immediate savings. The study's findings show they actually cost a little more during a person's first year in the program because that person is getting more services. Steadman said any savings don't show up for about a year and a half, and that can be a tough sell to the community.

Richard Hopper, Hennepin County's mental health judge, said he tells funders up front the program won't save money immediately, but that it will use money more wisely. Hopper said many of the mentally-ill people who get in trouble with the law, especially the homeless, end up at hospital emergency rooms.

"Well what does it cost for an emergency room doc to prescribe a medication? Probably about $750," Hopper said. "Well if they're in mental health court and you've made an appointment for them to see a doctor at the mental health center, it probably costs about $150."

Ramsey County also has a mental health court. County Commissioner Jim McDonough said the presentation reinforced his support of such courts, but he questioned whether overall they will ever save money. He said their value is in a safer community and a better quality of life:

"Great cost savings on an individual basis, but on a system-wide basis I'm not so sure that there's going to be a true cost savings to the taxpayer other than we'll be able to be providing more humane and appropriate treatment for people with mental health within the criminal justice system," McDonough said.

The study is in a second phase that will compare the actual costs and benefits of mental health courts with typical criminal courts.

Broadcast Dates

All Things Considered, 07/17/2009, 4:49 p.m.

Making the case for treatment:
Details on the interface between a local care system and the criminal justice system

by Kate K.V. Lawson, MPA; Michael R. Berren, PhD; and Neal Cash, MS

Behavioral Healthcare

The situation is not uncommon: A family member of an individual with a mental illness calls local law enforcement as a “last resort.” A situation has escalated to the point of being a crisis and, for everyone involved, it appears as though all other options have been exhausted. While the call is generally a last-ditch effort to ensure safety for the individual and/or others, law enforcement’s presence often results in the individual with a mental illness being arrested or detained. In addition to this scenario, it is not unusual for individuals with a mental illness to become involved in the criminal justice system for crimes that often are a consequence of their illness and/or social situation (such as vagrancy because the individual often has nowhere else to go). They then must manage the difficult task of negotiating a complicated criminal justice system while attempting to reengage in treatment. The criminalization of mental illness is hardly a new topic. It has been written about for decades, with an article by Abramson (1972) being one of the earliest.1 Following Abramson’s article have been hundreds of others addressing the issue of jails and prisons becoming primary housing facilities for individuals with mental illness. Not only is it a topic of concern for professional publications, the criminalization of people with mental illness regularly is addressed in the popular press. For example, a March 3 blog post on the Dallas Morning News Web site talked about a bill that would prevent local authorities from using “time and convenience” as reasons for incarcerating mental health patients.2 There are a myriad of reasons, however, why using the criminal justice system as a de facto mental health system is inappropriate, including the following. R26; Jails and prisons are ill-equipped to serve as mental health facilities. Where statistics are available, inmates with mental illness have higher than average disciplinary rates. A study in Washington State found that while inmates with mental illness constituted nearly 19% of the state's prison population, they accounted for 41% of infractions.3 This leads to the additional issue of inmates with mental illness who have problems with controlling their behavior being disproportionately placed in solitary confinement. Furthermore, solitary confinement is particularly difficult for inmates with mental illness because of limited medical care and the psychologically harmful consequences of isolation and idleness.
• While in detention medications may be discontinued or changed, and the variety of case management, skill building, and clinical services will be limited or eliminated completely.
• Incarceration is an expensive alternative to treatment. While prison can cost quite a bit more, even incarceration at the Pima County (Arizona) jail can cost nearly $100 per day.
• Once an individual’s treatment has been interrupted by incarceration it can be difficult to reengage him/her in services, thereby adding to the long-term costs.
• In addition to the costs to taxpayers and adverse impact on the individual, it is unethical to use incarceration and prison as an alternative to treatment.

Our response
Given all of the reasons for not wanting to inappropriately incarcerate individuals with mental illness, the Community Partnership of Southern Arizona (CPSA) collaborated with its provider network and the criminal justice system to form the Behavioral Health/Criminal Justice System Workgroup. The workgroup’s first task was to identify systemic issues that led to inappropriate incarceration and/or inappropriate length of stay. Following the identification of issues the workgroup began to focus on the strategies and interventions that could be implemented to reduce the time that an individual with a mental illness is inappropriately incarcerated. That is not to say that incarceration is always inappropriate. There are a variety of circumstances in which incarceration might be appropriate to protect an individual from being a danger to him/herself or others, or serve as an intervention before more serious destabilization occurs. Furthermore, incarceration may become a “wake-up call” for the individual as to the consequences of not properly managing his/her illness. One of the workgroup’s primary outcomes was creating the CPSA Criminal Justice Team, established to be a resource and link between the justice and treatment systems. The team works with behavioral healthcare provider agencies (each of which was mandated to employ a criminal justice specialist) and other stakeholders, such as courts, probation officers, pre-trial services, the jail, police departments, and attorneys, to facilitate resolutions of both system-wide and member-specific issues. To have a positive impact on inappropriate incarceration, the collaborative relationship between the various behavioral healthcare and justice entities must allow for information to pass quickly and efficiently, while at the same time observing applicable HIPAA rules and regulations. Contrary to popular belief, HIPAA rules do not necessarily have to be a barrier for communication between criminal justice and behavioral healthcare agencies. Rather, it can provide tools to aid in cross-system information sharing. For example, when an individual is detained in the jail, time is of the essence in transmitting critical behavioral healthcare information from the treatment provider in the community to the treatment provider in the jail. Failure to do so can result in further destabilization and crisis for the individual, thereby increasing risk of injury to the individual (including suicide), other inmates, and jail staff.

Collaborative strategies
The three most commonly used tools to share CPSA member-specific information within the Criminal Justice Team includes the following.

Provider-to-provider information sharing. To identify in real time clients who have just been arrested, twice a day the “booking list” of the county is filtered against the CPSA member roster. When a match is identified the Criminal Justice Team sends a notification to the criminal justice specialist at the behavioral healthcare agency, notifying him/her that a client in his/her network has been arrested. This real-time notification includes the charges, the client’s enrollment status within the behavioral healthcare system (SMI, substance abuse, etc.), the assigned court or jurisdiction, and the next court date. The Criminal Justice Team also notifies the contracted healthcare provider at the jail that an inmate in its custody is enrolled in the community behavioral healthcare system. A recent enhancement to the Criminal Justice Team initiative is to have a CPSA criminal justice team member attend the initial appearance court hearings (at which a judge determines conditions of release, if any, and informs the individual of the charges). The team member’s participation allows for: • A universal consent form (discussed below) to be signed
• An assessment to determine the individual’s ability to transport him/herself home and to treatment
• Information sharing with pre-trial services and the presiding judge For individuals not enrolled in the treatment system, the criminal justice team member facilitates the enrollment process and timeliness of having the person seen by a treatment provider. This recently implemented process has significantly increased the likelihood that the individual may avoid being taken into custody. If a CPSA-enrolled member is taken into custody, CPSA provider agencies are contractually required to submit to the jail healthcare provider clinical information, including medications the individual is taking, case management notes, and any other information deemed relevant. CPSA’s pharmacy staff also send the most recent pharmacy information to the jail’s healthcare provider. The jail healthcare provider, in turn, places individuals with mental illness on a specialized caseload, which allows them to be housed in acute or subacute mental health “pods” within the jail, if needed. On a weekly basis the CPSA Criminal Justice Team members, the behavioral healthcare agencies’ criminal justice specialists from, and the mental healthcare provider meet to discuss general issues and conduct staffing and discharge planning for inmates enrolled in the behavioral healthcare system. Individuals who have been identified as having a mental illness but not enrolled in CPSA may be referred/evaluated for enrollment while in custody. The team may coordinate transportation for individuals too unstable to leave the jail unassisted or assessment for court-ordered treatment for those who meet the legal criteria of danger to self, danger to others, persistently or acute disabled, or gravely disabled.

Universal consent form. The Criminal Justice Team developed and implemented use of an information-sharing universal consent form accepted by all providers in the CPSA system and readily used by all criminal justice entities, including court officials, attorneys, probation officers, and law enforcement. While a consent form is not required for all information-sharing activities (e.g., as ordered by a judge or to the healthcare provider at the jail), using the form not only establishes a recognition for the individual’s privacy, but also lets the individual know of every agency with whom his/her information will be shared and for what purpose. The form permits the Criminal Justice Team and providers to share real-time information, which may change daily depending on the person’s stability and criminal case processing. It also permits communication with multiple justice entities when cases are pending in more than one court or jurisdiction.

Mental health courts and judicial orders. A standardized judicial order for sharing healthcare information typically is used in the specialty mental health courts by judges who have received behavioral health training and understand these orders’ legal and medical implications. Standardized orders permit a level of sharing and collaboration that is even greater than allowed through the universal consent form. CPSA co-sponsored mental health courts are examples for how collaboration between various social service and criminal justice entities benefits the stakeholders, community and, most importantly, the CSPA members. CPSA has active mental health courts in five jurisdictions, as well as a consolidated justice court and felony superior court. Members enrolled in a mental health court have been found to be more compliant with treatment, resolve criminal charges more efficiently and effectively, and commit fewer new offenses. These outcomes result in improved public safety, cost savings to taxpayers, and better outcomes for our members.

Systemic strategies
HIPAA-compliant mechanisms for sharing member-specific information is only part of the process used by the community to make the most appropriate use of the criminal justice system as it concerns mental health patients. There are also a number of strategies to impact system-wide issues. Other collaborations that CPSA coordinates, or is an active participant in, include: • Pima County Forensic Task Force
• Mental health court steering committee
• Crisis intervention training with law enforcement
• Court-specific collaborative committees As a result of these collaborations, Southern Arizona has developed standards and ethics that value progressive programs that positively impact individuals with mental illness involved in the criminal justice system. Kate K.V. Lawson, MPA, is the Criminal Justice Manager at the Community Partnership of Southern Arizona (CPSA), the regional behavioral health authority coordinating and managing publicly funded behavioral health services in Cochise, Graham, Greenlee, Pima, and Santa Cruz Counties. Michael R. Berren, PhD, is CPSA’s Director of System Development and a clinical lecturer in the Department of Psychiatry at the University of Arizona. Neal Cash, MS, is President/CEO of CPSA. For more information, e-mail michael.berren@cpsa-rbha.org.

References
1. Abramson MF. The criminalization of mentally disordered behavior: possible side-effect of a new mental health law. Hosp Community Psychiatry 1972;23(4):101-5.
2. Ramshaw E. Keeping mental health patients out of jail [blog post]. Dallas Morning News. March 3, 2009. http://trailblazersblog.dallasnews.com/archives/2009/03/keeping-mental-health-patients.html.
3. Fellner J. A corrections quandary: mental illness and prison rules. Harvard Civil Rights-Civil Liberties Law Review 2006;41(2):391-412. http://www.law.harvard.edu/students/orgs/crcl/vol41_2/fellner.pdf Articles & Archives:
• Working to reunite families torn apart by mental illness
• Training video helps police work with mentally ill youth
• Learning from the ‘drama’ of police encounters

News:
• Study documents prevalence of serious mental illnesses among nation's jail populations
• Guide examines law enforcement responses to people with mental illnesses
• Mental health court program honors Centerstone employee
• NIDA study shows prisoners are not receiving drug abuse treatment
• Council of State Governments releases primer on mental health courts

New Study Released on Prevalence of Serious Mental Illness Among Jail Inmates

The lead article in the June issue of Psychiatric Services by Henry J. Steadman, PhD and colleagues found that 14.5% of male and 31.0% of female inmates recently admitted to jail have a serious mental illness.

The study was conducted by Dr. Steadman, Dr. Fred Osher, Pamela Clark Robbins, Brian Case, and Dr. Steven Samuels. All authors are affiliated with Policy Research Associates, Inc., except for Dr. Osher of the Council of State Governments Justice Center. The study was partially funded by the Justice Center.

The authors analyzed data collected from two time periods at multiple jails to calculate the prevalence of mental illness. Selection of inmates for clinical interviews was based on systematic sampling of data from a brief screen for symptoms of mental illness that was administered at admission for all inmates as part of earlier research by the authors. The screen was administered to 11,168 inmates during the first phase of data collection and 10,240 inmates during the second phase. A diagnostic interview protocol was administered to a total sample of 822 inmates and weighting procedures were applied to generate the prevalence estimates.

These findings confirm what jail administrators already know – a substantial proportion of inmates entering jails have a serious mental illness and women have rates two times those of men.

The article is available from Psychiatric Services: http://ps.psychiatryonline.org/cgi/content/abstract/60/6/761

View resources developed by the CMHS National GAINS Center on mental health/criminal justice interventions such as Practical Advice on Jail Diversion, Screening and Assessment of Co-Occurring Disorders in the Justice System, and Working with People in the Criminal Justice System: What Mental Health Service Providers Needs to Know: http://www.gainscenter.samhsa.gov/html/resources/publications.asp

View the services available from Policy Research Associates to improve your community’s response to justice-involved people with serious mental illness: http://www.prainc.com

View the brief prepared by the Council of State Governments Justice Center: http://consensusproject.org/updates/features/prevannouncement

From national NAMI

supporting schools and communities in breaking the prison pipeline:

A Guide to Emerging and Promising Crisis Intervention Programs for Youth

February 2009

The National Alliance on Mental Illness (NAMI) is the nation’s largest grassroots mental health
organization dedicated to improving the lives of individuals and families affected by mental
illness. NAMI has over 1,000 affiliates in communities across the country who engage in advocacy,
research, support, and education. Members of NAMI are families, friends, and people
living with mental illness such as major depression, schizophrenia, bipolar disorder, obsessivecompulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), and borderline personality disorder.

NAMI
2107 Wilson Boulevard, Suite 300
Arlington, VA 22201‐3024
Web site: www.nami.org
Telephone (703)‐524‐7600 or (800) 950‐NAMI (6264)

Supporting Schools and Communities in Breaking
the Prison Pipeline:
A Guide to Emerging and Promising Crisis Intervention
Programs for Youth
Dana Markey, Program Coordinator, NAMI Child and Adolescent Action Center
Laura Usher, Coordinator, NAMI Crisis Intervention Team (CIT) Resource Center
Darcy Gruttadaro, Director, NAMI Child and Adolescent Action Center
Ron Honberg, Director, NAMI Policy and Legal Affairs

Table of Contents
Acknowledgments............................................................................................................... 5
Introduction ........................................................................................................................ 5
The Critical Need for Crisis Intervention Programs for Youth ............................................ 7
What is the Crisis Intervention Team (CIT) Model?............................................................ 9
Case Studies: Crisis Intervention Programs for Youth ...................................................... 10
Key Components of Crisis Intervention Programs for Youth............................................ 12
Benefits of Crisis Intervention Programs for Youth .......................................................... 19
The Cost of Crisis Intervention Programs for Youth ........................................................ 20
Where Advocacy is Needed .............................................................................................. 21
Conclusion........................................................................................................................ 22
Resources .......................................................................................................................... 23
References ........................................................................................................................ 26
Tables
Table 1: Positive Behavioral Interventions and Supports................................................... 7
Table 2: Negative Outcomes for Youth with Mental Illness ............................................... 8
Table 3: Community Partnerships..................................................................................... 12
Table 4: Training Topics .................................................................................................... 15
Table 5: The Value of Cultural Competency ..................................................................... 18
Table 6: Adult CIT Works................................................................................................... 20

Acknowledgments
NAMI deeply appreciates the support of the Annie E. Casey Foundation for this project. We acknowledge
that the information, opinions, and commentary in this guide are those of NAMI,
and do not necessarily reflect those of the Casey Foundation. To learn more about their work,
visit www.aecf.org. We also wish to express our appreciation to the
many individuals who are leading this field, and who shared their time and expertise with us,
including: Keri Fitzpatrick, Sergeant Jon Van‐ Zandt, Carol Peters, Terri Mabrito, Lieutenant
Jeffry Murphy, Officer Kurt Gawrisch, Stacie Golden, Oscar Morgan, Mo Canady, among
others. We also appreciate the assistance of Jeny Beausoliel for copyediting this guide.

Introduction
This resource is designed to introduce children’s mental health advocates and other stakeholders
to models and practices that effectively respond to youth in psychiatric crisis in schools and communities. Also included are practical action
steps and strategies to guide advocacy leaders and other stakeholders in promoting and implementing
youth‐focused crisis intervention programs in their states and communities.
An alarming number of youth with serious mental health treatment needs continue to enter
the juvenile justice system. This happens for a variety of reasons, including a lack of psychiatric
crisis intervention services in schools and communities.
Many schools have proven to be a pipeline into the juvenile justice system with
school personnel contacting law enforcement when students engage in disruptive behaviors,
including cases involving a psychiatric crisis. A number of communities are focusing on developing
crisis intervention programs for youth. These programs are designed for both community
and school settings. This paper focuses on the Crisis Intervention Team (CIT) model, a dynamic
collaboration of law enforcement and community agencies and organizations committed
to ensuring that individuals with mental illness are referred to appropriate mental health
services and supports rather than thrust into the criminal justice system. This model has been
successfully used with adults for decades in states and communities across the country, with
outstanding results. A more detailed description of the CIT model is provided on page 9.
As a result of the extraordinary success of adult CIT, innovative states and communities are
working to adapt CIT to effectively respond to youth in crisis in communities and in schools.
CIT programs that work in schools are most important since youth spend most of their day
there. Communities adapting adult CIT and developing
crisis intervention programs for youth include the following:
♦ Denver, which has implemented Children in Crisis (CIC);
♦ San Antonio, which recently developed and piloted Children’s Crisis Intervention Training
(CCIT); and ♦ Chicago, which is currently developing CIT
for Youth. For this paper, NAMI has used these model programs
as case studies. These programs are relatively new and are in the development phase, so
they may change slightly as they are rolled out. NAMI identified and interviewed program developers,
law enforcement personnel, and school personnel across the country involved with
these cutting edge programs, including the following: ♦ Keri Fitzpatrick, Manager, Colorado Crisis
5 Intervention Teams, managing the Children
in Crisis program in Denver;1 ♦ Sergeant Jon VanZandt, Adam County’s
Sheriff’s Office, implementing the Children in Crisis program in schools in Denver;2
♦ Carol Peters, Principal, Clear Lake Middle School, embracing crisis intervention programs
in schools in Denver;3 ♦ Terri Mabrito, Youth Diversion Facilitator,
The Center for Health Care Services, implementing Children’s Crisis Intervention Training
in San Antonio;4 and ♦ Lieutenant Jeffry Murphy, CIT Coordinator,
Chicago Police Department, developing CIT for Youth in Chicago.5
NAMI also interviewed others involved with law enforcement training who provided additional
insight on crisis intervention programs for youth, including the following:
♦ Stacie Golden, Training Specialist, Idaho Departmen
of Health and Welfare, participated in the development and implementation
of a training video and training program for law enforcement personnel in
Idaho;6 ♦ Oscar Morgan, Ph.D., Technical Assistance
Coordinator, Idaho Department of Health and Welfare, participated in the development
and implementation of a training video and training program for law enforcement
personnel in Idaho;7 and ♦ Mo Canady, Training Director, National Association
of School Resource Officers, discussed the role of school resource officers
in crisis intervention programs for youth.8 Through these in‐depth interviews and extensive
research, NAMI gained a broader understanding of existing and emerging crisis intervention
programs for youth around the country, including the key program components, costs,
and benefits of these programs. NAMI also learned where advocacy efforts are most
needed. This paper is intended to provide advocates with
information they can use to promote the adoption of similar programs in their communities.
However, there is no need to re‐invent the wheel. Effective programs are being developed
and implemented that can be adapted to meet the needs of diverse communities.
This paper focuses on just one component of a much larger picture. Crisis intervention programs
for youth do not provide direct services, but instead provide an infrastructure that supports
community collaboration and provides schools and communities with a uniform approach
to addressing the needs of youth experiencing psychiatric crises. In some communities,
crisis intervention programs for youth have been a catalyst for change. For example, in the
San Antonio, Texas, case study, the CCIT program led to plans to expand the availability of
Mobile Crisis Units and related services. Ideally, schools and communities should be developing
and implementing an array of services that help to prevent crises by identifying children
with mental health treatment needs early and ensuring services and supports are provided
that prevent mental health conditions from escalating to a crisis. There are many programs
and services available that complement crisis intervention programs for youth, including educational
programs for school professionals and families, a wide array of home and communitybased
services, positive behavioral interventions and supports (PBIS), and mental health curricula
that reduce stigma and may increase help‐ seeking behavior among youth.

The Critical Need for Crisis Intervention
Programs for Youth Far too many youth with mental illness are landing
in the juvenile justice system. Research shows that 70 percent of youth in the juvenile
justice system have one or more psychiatric disorders. 9 At least 20 percent of these youth have
a serious mental illness, including those who are suicidal, struggling with psychotic disorders, and
experiencing symptoms that significantly interfere with their day‐to‐day functioning.10
Many of these youth are incarcerated for minor, non‐violent offenses, while others have not
been charged with a crime.11 Schools and families are often forced to involve
police when a child is experiencing a psychiatric crisis because alternatives do not exist. The police
are accustomed to handcuffing and transporting these youth to the juvenile justice system.
This is known as the school to prison pipeline. It disproportionably impacts youth with
mental health treatment needs. Yet, with more than 52 million students in
schools in the U.S., schools are in a unique and key position to identify mental health concerns
early and to link students with appropriate services. Goal 4 of the President’s New Freedom
Commission Report on Mental Health, issued in July 2003, calls for schools to play a larger role
in the early identification of mental health treatment needs in children and to link them to appropriate
services.12 Engaging schools in identifying children and adolescents with mental
health treatment needs promises to help reduce the lag time, often eight to ten years, from
when an individual first experiences the symptoms of mental illness to when they first seek
and receive treatment. Children and adolescents with mental illness are
not faring well in many communities across the country. This is true for a number of reasons.
Mental health services for children are fragmented and may be available in multiple systems,
including mental health, education, child welfare, juvenile justice, and primary care. The
fragmentation of services and lack of cross‐ Table 1. Positive Behavioral Interventions and Supports13
Positive Behavioral Interventions and Supports (PBIS) s a school‐based practice model that emphasizes
school‐wide systems of support with proactive strategies to create a positive school
environment and address students’ challenging behaviors . PBIS focuses on first understanding the underlying cause of a student’s negative behavior and
then developing a positive intervention plan that uses a collaborative team approach to address
the student’s individual needs. The PBIS approach is data‐driven and has produced the
following results:
♦ Research conducted over the past 15 years has shown that PBIS is effective in promoting
positive behavior in students and schools.
♦ Schools report increased time engaged in academic activities and improved academic performance.
♦ Schools indicate reductions in office discipline referrals of 20 to 60 percent.
♦ PBIS leads to dramatic improvements that have long‐term effects on the lifestyle, communication
skills, and problem behavior in individuals with disabilities.
♦ PBIS makes it easier to identify students who need intensive interventions and works collaboratively
with other service systems.
systems collaboration has often led to a lack of accountability. It has also led to many families
being forced to act as case managers for their children. There is also a lack of capacity in the
home and community‐based services available for youth. All of these factors have led to extremely
poor outcomes for youth with mental illness, as outlined in Table 2.
Research shows that 10 percent of youth have a serious mental illness.15 However, only 20 to 30
percent of these youth receive any mental health services; leaving over 70 percent of children
and adolescents with a diagnosable mental illness without services.16 Meanwhile, other
child‐serving systems like juvenile justice and child welfare must provide the mental health
treatment needs of youth, often without the training or personnel to do so.
Research shows that youth with mental illness fail more classes, earn lower grade point averages,
miss more days of school, and are retained more often at grade level than other students
with disabilities.14 School personnel and administrators have expressed frustration with poor
academic performance and disruptive behaviors of groups of students, including those with serious
mental health treatment needs. Law enforcement personnel express concern
that they are often used as the “big stick” in schools and communities when addressing
youth with mental illness. They are repeatedly contacted about the same individuals who are
not linked to mental health services and supports, resulting in repeated confrontations that
often lead to the unnecessary, costly incarceration of these youth in the juvenile justice system.
Community members become outraged when law enforcement personnel unnecessarily injure
or kill an individual who was acting out because of a mental illness and needed mental health
services. This situation can create great community unrest.
Families are frustrated that they are left with few alternatives other than to call the police
when their children are experiencing a psychiatric crisis. They are often not informed of other
Table 2. Negative Outcomes for Youth with Mental Illness
♦ 10% of children and adolescents in the U.S. live with a serious mental illness that
causes significant impairment in their dayto‐ day lives, yet only 20% of them are identified
and receive mental health services.17 ♦ 50% of students with a mental illness age
14 and older drop out of high school—the highest dropout rate of any disability
group.18 73% of those who drop out are arrested within five years.19
♦ Children with mental illness are more than three times as likely to be arrested before
leaving school as other students.20 ♦ Children with mental illness fail more
courses, earn lower grade point averages, miss more days of school, and are retained
at grade level more often that other students with disabilities.21
♦ Suicide is the third leading cause of death in youth aged 10 to 24.22 90% of people
who die by suicide have a diagnosable and treatable mental illness at the time of their
death.23 ♦ 70% of youth involved in state and local
juvenile justice systems have a serious mental illness, with at least 20% experiencing
symptoms so severe that their ability to function is significantly impaired.24
♦ Children with mental illness are twice as likely to be living in a correctional facility,
halfway house, drug treatment center, or “on the street” after leaving school compared
to students with other disabilities.25 8
resources or services that are designed to meet the needs of their children during a crisis.
These frustrations and the negative outcomes for youth with untreated mental illness underline
the critical importance of law enforcement, schools, communities, and families embracing
effective crisis intervention programs. These programs provide law enforcement personnel
and other first responders with the tools they need to respond compassionately and effectively
to youth in psychiatric crisis. They also promise to help break the steady flow of youth
with mental illness into the juvenile justice system. They will also lead to safer outcomes
when law enforcement must get involved. Children’s mental health advocates play an important
role in building the momentum and interest in crisis intervention programs for youth
and in bringing together the stakeholders needed to ensure the effective implementation
and sustainability of these programs.

What is the Crisis Intervention Team
(CIT) Model? The Crisis Intervention Team (CIT) model is designed
to improve the outcomes of interactions between law enforcement personnel and individuals
with mental illness. When individuals with mental illness are experiencing
a psychiatric crisis or are acting out as a result of a mental illness, CIT works by diverting
them to appropriate mental health services and supports rather than to the criminal justice system.
CIT provides training to law enforcement personnel on preventing psychiatric crises and deescalating
a crisis when it occurs, without the unnecessary use of physical force. However, CIT
is not just a training program. CIT programs are only effective when law enforcement personnel,
the community mental health system, consumer and family advocates, and other stakeholders
collaborate to help ensure that when officers divert an individual, the treatment system is
willing and able to provide appropriate services. Until recently, CIT training focused primarily on
addressing the needs of adults, although trained officers have also long responded to calls involving
youth in psychiatric crises. Adult CIT has three key components:
♦ A community collaboration between mental health providers, law enforcement personnel,
family and consumer advocates, and other stakeholders. Representatives from
these stakeholder groups form a steering committee or advisory group. They examine
local systems to determine their community’s needs, agree on strategies for meeting
those needs, and organize training for law enforcement personnel. This committee
also determines the best way to transfer 9
people with mental illness from police custody to the community mental health system
and ensures that there are adequate services for triage.
♦ A 40‐hour training program for law enforcement personnel that includes basic information
about mental illness, information about the local mental health system and local
policies, interaction with consumers and family members to learn about their experiences,
verbal de‐escalation techniques and strategies, and role‐playing.
♦ Consumer and family involvement in steering and advisory committees, coordinating
training sessions, and leading training sessions. The first CIT program was established in Memphis
in 1988 after a police officer shot and killed a man with a serious mental illness. This tragedy
prompted a collaborative effort between the police, NAMI Memphis, the University of Tennessee
Medical School, and the University of Memphis to improve police training and procedures
in response to calls involving individuals with mental illness. The Memphis CIT program
has achieved remarkable success, in large part because it has remained a true community partnership.
Today, the so‐called “Memphis Model” CIT has been adopted by hundreds of communities
in more than 40 states, and is being implemented statewide in several states.
Building on the success of CIT programs for adults, several communities have started to
adapt CIT programs for youth. Some of these communities are spotlighted in the next section
and are utilized as case studies throughout this paper.

The Case Studies: Crisis Intervention Programs for Youth
The crisis intervention programs for youth briefly described below were chosen as case
studies for this paper because they are comprehensive and follow the overarching guidelines
set for adult CIT programs. These programs are described and compared in further detail in
subsequent sections of this paper. Children in Crisis (CIC)
Denver, Colorado CIC levels the playing field so everyone is working
from the same sheet of music…everyone wins! I cannot imagine law enforcement not
wanting this; it goes a long way with kids. ‐ Sgt. Jon VanZandt, Adams County Sheriff’s
Office Children in Crisis (CIC) is a regionally‐based program
designed to divert youth with mental illness from the juvenile justice system by using
appropriate crisis intervention responses and services.
One of the components of this CIT‐based program is training for law enforcement personnel,
including school resource officers (SROs), and school administrators. This program is designed
to improve crisis intervention responses with youth and in schools by training officers on
mental health issues, de‐escalation and problem solving techniques, and methods for connecting
to child and adolescent resources. As with any CIT‐based program, a key component
of the program is the development of local partnerships between stakeholder groups.
CIC was developed by a CIT stakeholder group, including a number of local law enforcement
agencies and juvenile justice professionals, under the Colorado Regional Community Policing
10 Institute (CRCPI). The program was piloted in
2006. The program is available to be implemented in
other communities, however, the community partnerships described above must be in place
before program implementation. The program is currently being revised as part of
a national Models for Change multi‐state project, funded by the MacArthur Foundation.26
The updated and revised program will be named CIT for Youth.
For more information about CIC, please visit www.dcj.state.co.us/crcpi (Click “CIT”).
Children’s Crisis Intervention Training (CCIT) San Antonio, Texas
If you can bridge the gap between school districts and police departments and youth with
mental illness, that makes all the difference. Safety is the first thing on a school administrator’s
mind, so it is important to emphasize that the program is in tune with those concerns.
‐ Terri Mabrito, Youth Diversion Facilitator, The Center for Health Care Services
The Children’s Crisis Intervention Training (CCIT) program focuses on training school campus officers
and school resource officers (SROs) to respond to children and youth in psychiatric crises
and divert them to mental health treatment. This provider‐driven, community‐based program
involves various community organizations, youth, and families in implementing the program
and developing community partnerships for sustainability.
The program was developed by youth‐focused community partners and stakeholders with
leadership and coordination by the Center for Health Care Services in Bexar County. The program
was piloted in 2008. The program is available to be implemented in
other communities. Fine tuning will help the program fit the uniqueness of any community,
particularly with respect to the unique needs and resources of school districts and their police
departments. For more information, contact Terri Mabrito,
Community Liaison, Youth Diversion Facilitator, The Center for Health Care Services, at
tmabrito@chcsbc.org. Crisis Intervention Team (CIT) for Youth
Chicago, Illinois The officers at school are at the front entrance
to the juvenile justice system. They need more support. They should not just be used as the
‘bad guys.’ ‐ Lt. Jeffry Murphy, Chicago Police Department
Chicago’s CIT for Youth program, which is still in development, will focus on diverting youth from
the juvenile justice system to mental health treatment. The program will target schoolbased
police officers and will work closely to develop a hand‐in‐hand partnership with
schools. The program includes the promotion and delivery of supplemental programs that
educate school professionals on mental illness. CIT for Youth is being developed by the Chicago
Police Department and is expected to be available for dissemination in 2009. However, it will
likely require adaptations to successfully meet the needs of diverse communities.
For more information, contact Officer Kurt Gawrisch, Crisis Intervention Team, Chicago Police
Department, at: kurt.gawrisch@chicagopolice.org.

Key Components of Crisis Intervention
Programs for Youth Those involved with the Children in Crisis (CIC),
Children’s Crisis Intervention Training (CCIT), and Crisis Intervention Team (CIT) for Youth programs,
identified the following seven (7) key components to an effective and sustainable crisis
intervention program for youth:

1. Community Partnerships
2. Needs Assessment 3. Planning
4. Oversight and Feedback

5. Training
6. Involvement of Youth and Families

7. Outcomes Research

Below is more detailed information on each of these components.
1. Community Partnerships: Cast the widest net of all stakeholders and let
them have input on all the issues. ‐ Lt. Jeffry Murphy, Chicago Police Department
A successful program that responds to children and youth in crisis should be built on community
partnerships between youth and their families, community mental health providers, law enforcement
personnel, school personnel, the juvenile justice system, and other stakeholders
that youth with mental health treatment needs may encounter in their daily lives.
Table 3: Community Partnerships Denver Children in Crisis (CIC) Community Partners: CIC programs are regionally based, and local stakeholders assist with program development and implementation. Each region has partners from their community, including law enforcement agencies, juvenile justice, local prosecutors, behavioral health professionals, and family and advocacy groups.
San Antonio Children’s Crisis Intervention Training (CCIT) ommunity Partners: Partners for this
program include Bexar County Judge’s Children’s DiversionInitiative, San Antonio Independent
School District Police Department, Education Service Cente/Region 20, School Districts, The Alamo
Area Council of Governments, San Antonio Police Department, The Bexar County Sheriff’s Department,
NAMI San Antonio, hospitals, school campus police officers, mental health providers, and
families.
Chicago CIT for Youth Community Partners: Partners for this program include NAMI, the juvenile
court system, the local children’s hospital, school boards, and representatives from the adult CIT
program. Community partnerships continue to be developed for this program.
NAMI also suggests including the following community partners:
♦ Universities and Research Organizations
♦ Staff from Parole and Probation
♦ Homeless Shelter Staff
♦ Teen Runaway Organizations and Programs
The National Association of School Resource Officers (NASRO) recommends SROs as valuable partners
in crisis intervention programs for youth since they bridge the gap between schools and law
enforcement agencies.

Table 3 lists the community partners that CIC, CCIT, and CIT for Youth program developers
have reached out to during the planning and implementation of their programs. NAMI also
includes recommendations on additional key partners.
Community partnerships are important for several reasons:
Solving the underlying problem. Research shows that 70 to 80 percent of children and
adolescents with a diagnosable mental illness fail to receive mental health services.27 These
youth often experience devastating consequences, including involvement with the juvenile
justice system, academic failure, the loss of
critical developmental years, and suicide. Community partnerships increase the likelihood that
youth will be identified early and linked with appropriate mental health services and supports
by providing stakeholders with information, support, services, and resources. They also connect
key players in children’s lives and ensure that key community organizations work together
to achieve the best possible outcomes. Funding. Additional funding streams are likely
to open up to support a crisis intervention programfor youth if partnerships are developed
that encourage combined funding. Also, funders and grantors are more likely to support collaborative
efforts and commitments. Long‐term sustainability. A crisis intervention
program built on community partnerships is more likely to endure with the active involvement
of multiple organizations rather than a program sustained by a single organization.
Accountability. Each stakeholder group involved in a crisis intervention program for youth
has a responsibility to others in the group and to youth impacted by the program. Building a
strong working relationship is the key to productively resolving problems that may arise in the
future. 2. Needs Assessment
A needs assessment is the most important step to implementing a crisis intervention program for
youth. ‐ Terri Mabrito, Youth Diversion Facilitator, The
Center for Health Care Services It is critically important that a needs assessment
by community stakeholders take place before implementation of a crisis intervention program
for youth. The assessment will help determine the availability of local resources, the community's
needs, and possible additional partners. This step will create an infrastructure to effectively
link youth with mental health treatment needs to appropriate services and supports.
In San Antonio, Texas, program developers worried that there was a lack of capacity in schools
and communities to support any additional youth that may be identified as needing mental health
services through the CCIT program. However, after conducting a needs assessment, they discovered
that many resources existed, yet knowledge of community resources, service coordination,
and case management was lacking. Program developers believe that CCIT fills the gaps
identified in the needs assessment since the program helps SROs develop greater knowledge of
local resources and therefore helps link youth to services rather than juvenile detention.
One useful exercise for a needs assessment is to create a “map” of existing services and systems
that youth encounter if they experience a psychiatric crisis. Then gaps in that network and areas
for service improvement can be identified. This will help in the creation of a “map” of services
and supports that should be available to youth experiencing a psychiatric crisis. This exercise
can also help identify additional partners that should be invited to participate in the program.
13 3. Planning

Community partners should work together to develop a plan that defines their roles and responsibilities
in implementing crisis intervention programs in their schools and communities. In
addition, the plan should address funding, ensuring support from critical stakeholders, program
sustainability, and related issues. The plan should also facilitate communication between
school personnel, law enforcement personnel, families, and mental health providers about
youths’ needs, describe how to transfer youth to crisis services and supports when necessary,
and ensure that youth receive appropriate community mental health and special education services
once diversion occurs. The policies of crisis intervention programs for
youth should comply with federal and state privacy and special education laws. Policies and
procedures should also emphasize safety and producing the best possible outcomes for youth
with mental health treatment needs. They should also focus on engaging families in decisions
related to services and supports needed to ensure positive outcomes for their children.
NAMI encourages families and advocates to proactively participate in the planning process to
ensure that the youth and family perspectives are incorporated throughout the process.
4. Oversight and Feedback Crisis intervention programs for youth should
have an oversight, advisory, or steering committee that fields inquiries about the program,
plans training sessions, and fosters ongoing communication between stakeholders, including
youth and families. The committee should also be responsible for creating a mechanism that
allows school personnel, law enforcement personnel, families, and youth to offer feedback
about the program. The CIC, CCIT, and CIT for Youth programs each
have a committee that includes a representative from each stakeholder group involved in the
program, including, at a minimum, school personnel, law enforcement personnel, community
mental health providers, and NAMI or other family advocacy organizations.
5. Training The curriculum should make good use of everyone’s
time, sections should first be developed on a “need to know” level, and then add in “nice to
know” areas to provide further anchors. ‐ Keri Fitzpatrick, Manager, Colorado CIT
The training curriculums for the CIC, CCIT, and CIT for Youth programs have some similarities to
adult CIT courses, but focus on a number of additional issues including brain development,
school related issues, and how mental illness impacts youth.
Program developers emphasized the importance of the following in training: teaching effective
verbal de‐escalation techniques, the need to use adult learning styles during the
training, and the need to dedicate at least 25 percent of the total training time to role playing
exercises so training participants can practice the skills they learn. Verbal de‐escalation skills
provide participants with safe and effective techniques to communicate with youth and to
calm a crisis situation. The CIC training program is certified and approved
by the Colorado Peace Officer Training
and Standards Board (POST). The CCIT program provides Continuing Education
Units (CEUs) to training participants. It has been approved by the Texas Commission on Law
Enforcement Officer Standards and Education (TCLEOSE).
14 Program developers shared that providing CEUs
for the training provided a great incentive for law enforcement personnel to participate.
Table 4 outlines the topics covered in the three crisis intervention programs for youth featured
in this paper. The length of the training varies by program:
♦ CIC has 24‐hour training, spread over three days;
♦ CCIT has 40‐hour training, spread over four days; and
♦ CIT for Youth has 40‐hour training, spread over five days.
Program developers determined the length of training by coordinating with law enforcement
agencies on the amount of available time they have to dedicate to a training program. It is important
to seek feedback from training participants on the length of training in case adjustments
are needed to ensure the training is effective, works within the schedule of law enforcement
personnel, and is well attended. Variation also exists between the three programs
on whether adult CIT training is a prerequisite for training participants. All three programs
are building upon the success of the adult CIT program in their community; however, officers
do not have to necessarily take both trainings. CIC and CCIT do not require both trainings,
however, Chicago’s CIT for Youth program will. NAMI believes communities should work toward
providing crisis intervention programs for both children and adults.
Table 4. Training Topics Denver Children in Crisis (CIC) Training Topics
♦ Introductions and Overview ♦ Child and Adolescent Development
♦ Child and Adolescent Psychiatric Disorders ♦ Communication and De‐escalation Skills
♦ Suicide and Self‐injurious Behavior ♦ The Family Experience
♦ Legal Issues ♦ Substance Abuse and Co‐occurring
Disorders ♦ Special Education
♦ Developmental Disabilities ♦ Connecting to Resources
San Antonio Children’s Crisis Intervention Training (CCIT) Training Topics
♦ Introduction to Crisis Intervention ♦ Officer Tactics and Safety
♦ Active Listening and De‐escalation Techniques
♦ Mental Illness in Children ♦ Legal Issues and Emergency Detention
♦ Child Abuse and Neglect and Duty to Report ♦ Brain Development and Developmental
Disorders ♦ Informed Consent
♦ Suicide Intervention ♦ Learning Disabilities
♦ Family and Child Perspective ♦ Cultural Competency and Diversity
♦ School Policies ♦ Community Resources
♦ Psychotropic Medications Chicago CIT for Youth Training Topics
♦ History and Overview ♦ Brain Development
♦ Signs and Symptoms of Mental Illness ♦ Risk Assessment and CIT Skills
♦ Developmental Disabilities ♦ Family Issues
♦ Self‐Injury and Suicide ♦ Substance Abuse and Chemical Dependency
♦ Urban Trauma of Mental Illness ♦ Information on Peer Pressure, Gangs, Violence,
and Bullying
♦ Resources in the Community 15
Each of the crisis intervention programs for youth have a dynamic mix of training instructors
that represent various community stakeholders involved with the program, including school personnel,
law enforcement personnel, mental health providers, youth and their families, and
others. The CIC program requires training participants
to complete a community resource worksheet to help participants identify important community
resources. This community resource sheet identifies local agencies and resources in the
school and in the community that support children and families and can assist in referral efforts.
The worksheet asks about school policies, local NAMI affiliates and other advocacy organizations,
juvenile justice staff contacts, and school contacts.
CCIT is planning to replicate the community resource worksheet, in addition to the current
materials they provide during training, which includes: a binder with instructors’ PowerPoint
presentations; handouts; and a “cop card” that contains brief information on CIT guidelines,
safety reminders, medical clearance, referral information, common psychotropic medications,
and questions to ask a consumer during a psychiatric crisis.
During their training, Chicago’s CIT for Youth program, embeds NAMI’s Parents and Teachers
as Allies into the training curriculum. Parents and Teachers as Allies is a two‐hour program,
originally designed for school professionals, that educates participants on the early warning signs
of mental illness in children and adolescents and how best to intervene so that youth with mental
health treatment needs are linked with services. It also covers the lived experience of mental illness
and how schools can best communicate with families about mental‐health related concerns.
The program is being used by the Chicago Police Department to help targeted
schools better understand early‐onset mental illness and to improve collaboration with
schools. NAMI encourages crisis intervention programs
for youth to also integrate cultural competency into their training, as outlined in Table 5.
NAMI has provided a list of valuable resources at the end of this paper for law enforcement
personnel that could be adapted and disseminated during training sessions.
6. Involvement of Youth and Families It is important to consider how to get a child’s
story told. ‐ Lt. Jeffry Murphy, Chicago Police Department
All the crisis intervention programs for youth that NAMI researched include training sessions
on the “family and youth perspective” that allow families to share personal stories and provide
law enforcement personnel the opportunity to interact one‐on‐one with families. Program
developers have identified challenges in having youth consumers serve as training presenters
and as role players, citing liability concerns and consistency issues. They have offered
the following ideas to increase youth participation: use young adult actors, videotape youth
consumers, or use youth without mental illness for the role playing segments.
NAMI suggests that training programs consider engaging an older consumer who can share his
or her experiences as a youth with mental illness. This has proven effective in NAMI signature
education programs. CIC, CCIT, and CIT for Youth, have already or are
planning to include family representation on the committees that oversee the programs. NAMI
also recommends proactively seeking feedback from youth and families on their experiences
with these crisis intervention programs to help ensure the ongoing effectiveness of the program.
16 7. Outcomes Research
CIC and CCIT have limited quantitative data on the effectiveness of their programs. However,
both programs have collected anecdotal stories of the benefits of the programs, which are provided
in the next section of this paper. The CIC program has a pre/post test for training
participants. The program evaluation, outside of the training evaluation, is still in development.
It may include additions to the CIT Tracking Form that is used for adult CIT programs.
This form is not standardized but usually includes information on the disposition of the law
enforcement call (e.g. arrest, emergency hold, transport to the hospital, etc.). It also includes
information about any crime committed, the use of force, and any resulting injuries to officers,
consumers, or bystanders. The CCIT program includes a program evaluation
that rates each training presenter and the training session as a whole.
Chicago’s CIT for Youth program is still developing their evaluation component, which may also
mirror the current CIT Tracking Form. The program has plans to partner with a local university
to assist in evaluating the program. NAMI encourages crisis intervention programs
for youth to partner with a university or research organization to conduct an evaluation of
both the training and the program in producing positive outcomes for youth. This data is important
to improving the program, providing support for expansion of the program, and to help
“make the case” to potential funders. It is important that baseline data be collected
before program implementation so the program’s effectiveness in producing positive outcomes
can be measured. Evaluations for crisis intervention programs for
youth should measure the following outcomes, among others:
♦ Number of contacts between youth and law enforcement personnel.
♦ Number of youth with mental health treatment needs who are linked to appropriate
mental health services and supports. ♦ Number of youth who are sent to the juvenile
justice system by schools. ♦ School attendance of students involved in
the program. ♦ Injuries sustained by bystanders, youth, and
law enforcement during encounters between law enforcement and youths with
mental health treatment needs. ♦ Use of force by law enforcement personnel
during encounters with youth experiencing psychiatric crises.
♦ Stakeholder attitudes about the resources available to meet the needs of youth with
mental illness. ♦ Youth and family experiences interacting
with community law enforcement, school resource officers, and other school personnel,
when a youth has a psychiatric crisis or extreme behavioral challenges.
17 Table 5. The Value of Cultural Competency28
Crisis intervention programs for youth should be culturally ompetent to ensure effectiveness in
diverse communities. Cultural competence integrates knowedge and information about individuals
and groups into specific program approaches and technique.
Cultural competency helps break down the barriers that impede communication and limit program
and service effectiveness in diverse communities. Effective communication, both verbal and nonverbal,
is key in crisis intervention programs for youth since law enforcement personnel must develop
trust and rapport with youth experiencing psychiatric crises. To help ensure cultural competency
in bringing crisis intervention programs for youth to communities, stakeholders should take
the following steps:
♦ Recognize the broad dimensions of culture (including age, religion, social groups, ethnicity,
and race). Age is clearly important in crisis intervention programs for youth.
♦ Examine the demographics of the targeted community. Identify the most prominent cultures
in the community and develop and integrate information and strategies on working with these
cultures into the crisis intervention program for youth.
♦ Include leaders from the most prominent cultural communities in the decision‐making process
and in advisory committees.
♦ Open a dialogue with members of the most prominent cultural communities to better understand
their needs. They will be able to provide useful information, including:
♦ Views on mental illness, accessing support, and law enforcement.
♦ Barriers to accessing mental health services and supports.
♦ The meaning of gestures in their culture (e.g. for some cultures, avoiding eye contact
is a form of respect and not a sign that someone is lying).
♦ Respect families as a primary source for identifying needs and priorities in mental health services
and supports and crisis intervention programs.
♦ Ensure that all stakeholders involved in the crisis intervention program for youth embrace and
welcome diverse cultures.

Benefits of Crisis Intervention Programs for Youth
Crisis intervention programs for youth are relatively new, so research on the positive outcomes
achieved by these programs for communities, law enforcement, schools, youth, and
families is limited. However, the program developers, school personnel, and law enforcement
personnel NAMI interviewed for this paper have shared the following anecdotal benefits of program
implementation: Benefits to Law Enforcement Personnel
♦ Teaches law enforcement personnel skills to effectively communicate with youth and
to effectively work in the school environment. ♦ Reduces the need for the use of force in a
crisis, therefore, reducing the trauma experienced by police officers who injure
youth, and improves the safety of law enforcement personnel.
♦ Uses a community policing model that includes a proactive approach to preventing
tragedy. ♦ Increases the chances that youth are referred
for mental health services so future confrontations with law enforcement can
be avoided. Benefits to Schools
♦ Breaks the school to prison pipeline, which increases the likelihood that students with
mental illness will remain in school and succeed academically, socially, and developmentally.
♦ Allows trained school‐based officers to serve as a resource for families, provide services
to youth, and participate in Individualized Education Plan (IEP) meetings, when
appropriate. ♦ Ensures consistency in a school’s approach
to responding to psychiatric crises. ♦ Provides a proactive approach to preventing
crises in schools. ♦ Increases school safety.
Benefits to Communities ♦ Increases community collaborations, which
enhances the tools and resources available to address the needs of youth with mental
illness. ♦ Reduces the number of youth with mental
health treatment needs in the juvenile justice system.
♦ Provides a uniform procedure for schools and communities to address psychiatric crises.
♦ Helps to prevents community tragedies. ♦ Links youth with mental illness to services
in the community, and may reduce the need for treatment in more costly and restrictive
settings. Benefits to Youth
♦ Ensures the safety of youth consumers. ♦ Reduces the trauma that is experienced by
those experiencing the crisis and peers who witness a dramatic, physical altercation.
♦ Increases the likelihood that youth will stay out of the criminal justice system, and remain
in school and in their communities, where they belong.
♦ Reduces the lag time between the first onset of mental health symptoms and when
an intervention is provided. Research studies on adult CIT programs show
that CIT keeps adults with mental illness out of jail and helps them access treatment. It also
reduces officer injuries, reduces SWAT team emergencies, and reduces the amount of time
officers spend on the disposition of mental health‐related calls. This information is outlined
in more detail in Table 6. Crisis intervention programs for youth are expected to have similar
outcomes and benefits once they are evaluated for effectiveness.

The Cost of Crisis Intervention Programs for Youth
I always say that it does not cost anything to think differently.
‐ Keri Fitzpatrick, Manager, Colorado CIT CCIT and CIC program developers shared that
crisis intervention programs for youth can be implemented and sustained at low cost through
strong community partnerships. CIC has encountered some challenges with
funding since law enforcement training programs have traditionally been cut during times
of fiscal crisis. Financial barriers have made buy‐in for the program challenging. In order to
help with buy‐in, CIC uses individuals that were originally resistant as spokespersons for the program.
The program also uses police commanders who can speak to the necessity of this training,
and who recognize that the program is effective for law enforcement. The program,
though administered by the state, considers the fiscal needs of local regions and their ability to
deliver a course. Since its inception, CIC training has been held in different regions with the support
of the Colorado Regional Community Policing Institute (CRCPI). Under the revised model,
regions will be allowed to deliver the course using their own subject matter experts, and if
needed, tailoring some areas to fit local needs. Typically, subject matter experts volunteer their
services. In the adult CIT program, cost reduction strategies are often shared across regions
and it is anticipated that the same type of information sharing will occur with the CIC program.
CCIT does not currently receive any funding. In order to sustain the program, it relies on free
resources, volunteers, and in‐kind donations from community partners.
Table 6: Adult CIT Works ♦ Studies show that CIT significantly reduces
arrests of people with serious mental illness. Pre‐booking diversion, including CIT,
reduced the number of re‐arrests by 58%.29,30
♦ Participants in CIT spend, on average, two more months in the community than individuals
who are not diverted through CIT.31 ♦ Individuals diverted through CIT and other
programs receive more counseling, medication, and other forms of treatment than
individuals who are not diverted.32 ♦ CIT training reduces officer stigma and
prejudice toward people with mental illness. 33
♦ CIT officers do a good job of identifying individuals who need psychiatric care34 and
are 25% more likely to transport an individual to a psychiatric treatment facility than
other officers.35 ♦ In Memphis, officer injuries sustained during
responses to “mental disturbance” calls dropped 80%.36
♦ In Albuquerque, the number of crisis intervention calls requiring SWAT team involvement
declined by 58%.37 ♦ In Albuquerque, police shootings declined
after the introduction of CIT.38 ♦ Officers trained in CIT rate the program as
more effective at meeting the needs of people with mental illness, minimizing the
amount of time they spend on “mental disturbance” calls, and maintaining community
safety, than officers who rely on a mobile crisis unit or in‐house social workers for
assistance with “mental disturbance” calls.39
20 NAMI has developed the following recommendations
to ensure crisis intervention programs for youth function at low cost:
♦ Coordination and Planning: Any member of the community partnership—NAMI advocates,
community mental health providers, law enforcement personnel, or school personnel—
may have staff members who can act as a program coordinator to plan training
sessions and committee meetings. ♦ Instructors: Local mental health professionals,
school personnel, law enforcement personnel (especially those with adult CIT training),
consumers, and family members are often willing to donate their time as panelists
and role players for the training. ♦ Facilities: Many programs host trainings at
the local law enforcement training academy, schools, or university facilities, for little to no
cost. ♦ Materials: Law enforcement agencies may
be willing to donate the cost of manuals and promotional materials.
♦ Salary: Officers selected for training should be volunteers who are invested in the program,
rather than motivated by a pay increase. Some communities may choose to
offer trained law enforcement personnel a token increase in pay in recognition of their
specialized skills or certifications. Law enforcement agencies may be able to cover
any additional staff costs incurred by taking officers off the street for the training.
♦ Sustained Funding: Once a program is established, opening the classes up to officers
from other communities and charging tuition can help create a sustainable funding
stream.

Where Advocacy is Needed
Powerful advocates are needed system‐wide to have an impact on resistance.
‐ Lt. Jeffry Murphy, Chicago Police Department CIC, CCIT, and CIT for Youth program developers
identified three critical areas where advocates can be most effective in promoting crisis intervention
programs for youth. Program developers of a training video and training program in
Idaho also shared their thoughts on ideas for effective advocacy strategies. NAMI has condensed
the information shared by these program developers into three overarching action
steps for family advocates. NAMI is developing advocacy fact sheets that will build upon these
three central areas of focus as well as discuss the challenges to implementation that those
interviewed identified. These resources will be posted on NAMI’s CIT Resource Center at:
www.nami.org/cit.

Build Momentum
Advocates are in a unique position to connect with community stakeholders that are essential
to the implementation and sustainability of crisis intervention programs for youth. Building
momentum can include: ♦ Sharing the benefits of crisis intervention
programs for youth with community stakeholders and connecting with other key partners
on this issue; ♦ Identifying boundary spanners, which are
people who have multiple relevant roles and experiences. Such individuals can include
a police officer who is a trained psychologist
or a family member who is also a teacher. These boundary spanners can
serve as spokespersons and ease communication between various stakeholder groups;
and ♦ Promoting crisis intervention programs for
youth to elected officials and the local media. Advocates should share their positive
personal stories and experiences. 21
Advocates need to get legislators’ ears. ‐ Oscar Morgan, Ph.D., Technical Assistance
Coordinator, Idaho Department of Health and Welfare
Reach Out to Law Enforcement Several program developers referenced wary
relationships between those in the mental health field and law enforcement personnel.
They emphasized that it is important for advocates to take the time to build a positive relationship
between mental health advocates and law enforcement officials. This can be achieved
by: ♦ Participating in “ride‐alongs” with officers
to understand their culture, concerns, and experiences;
♦ Reporting positive experiences with law enforcement and police officers who “do the
right thing” when it comes to interacting with individuals living with a mental illness.
It is important to promote positive media coverage of law enforcement agencies and
individuals who do a good job addressing mental health issues;
♦ Building relationships with law enforcement personnel who have a vested interest in
children’s mental health, including a police officer who has a child with a mental illness,
a school resource officer, or a police officer who is a mental health clinician; and
♦ Holding awards ceremonies and annual dinners for officers who have dedicated themselves
to becoming trained CIT officers. Advocates play a valuable role in sharing their
personal experiences with stakeholders as well as providing officers with a first person account
of “what went right” during a mental health crisis call.
‐ Keri Fitzpatrick, Manager, Colorado CIT Improve the School Environment
Although crisis intervention programs for youth often do not require approval by school administrators
when training is done through law enforcement agencies, program developers still
emphasized the key role schools play in the
process. Schools are especially important because they are in the unique position to identify
mental health concerns in students early and to link them to mental health services and supports.
This often helps to prevent crises from occurring. Program developers emphasized that
advocates should work within the school environment to help open the door to crisis intervention
programs for youth and to implement school‐based programs that are complimentary
to the program. This work can include: ♦ Promoting training programs that educate
school personnel about mental health issues; ♦ Encouraging school administrators to implement
Positive Behavioral Interventions and Supports (PBIS); and
♦ Building relationships with school counselors, social workers, and school resource officers,
who can advocate for crisis intervention programs for youth.

Conclusion

Our research revealed that families, schools,
and communities have an overwhelming interest in programs that effectively respond to
youth with mental illness in crisis. In this guide, we have outlined the critical need for these programs,
and discussed emerging and promising programs in Denver, San Antonio, and Chicago.
These communities, and many others, have begun to address the needs of youth with mental
illness by adapting Crisis Intervention Team (CIT) programs. The examples in this paper can serve
as a guide for advocates and others interested in promoting and implementing crisis intervention
programs for youth in their communities.

Resources

Adult CIT Programs with Youth Components
The crisis intervention programs for youth featured in this wte paper are youth‐focused and
aim to better meet the unique needs of youth with mental ilness by emphasizing community
collaboration and early identification. There are also adult CT programs that incorporate youth
components into the training curriculum, sometimes as an atecedent to developing a program
focused on youth. Examples of such adult CIT programs, inlude:
Connecticut Alliance to Benefit Law Enforcement (CABLE) www.cableweb.org
Georgia CIT Training Curriculum: Interventions with Children and Adolescents
www.namiga.org/CIT Adult CIT Resources
The Center for Mental Health Services’ (CMHS) National GAiNS Center
www.gainscenter.samhsa.gov/html/default.asp
Council of State Governments Justice Center
www.justicecenter.csg.org/resources/mental_health
Criminal Justice Mental Health Consensus Project
www.consensusproject.org
NAMI’s CIT Advocacy Toolkit
www.nami.org/cittoolkit
Police Executive Research Forum
www.policeforum.org
University of Memphis CIT Center
www.cit.memphis.edu
Juvenile Justice and Mental Health Reform
Models for Change
www.modelsforchange.net
National Center for Mental Health and Juvenile Justice
www.ncmhjj.com
National Center for Youth Law
www.youthlaw.org

Law Enforcement Resources
Manual: Responding to Children and Youth with Mental Health Needs
Developed by the Indiana Federation of Families for Children’s Mental Health (IFFCMH), this
manual covers a wide array of topics, including mental health disorders, psychiatric medications,
on scene assessment, clinical recommendations, public safety, intervention tips, and resources.
IFFCMH is also currently working on a program to train police officers and other professionals
about how to recognize the signs of emotional, behavioral, and mental issues in children and
adolescents and how to work with these young people and their families in a way that is most
beneficial to everyone. For more information, visit www.indianafamilies.org (Click on “IFFCMH
Police Training”)
National Association of School Resource Officers
www.nasro.org
Police Pocket Guide: Responding to Youth with Mental Health Needs
A comprehensive police pocket guide written by mothers of youth with mental illness and funded
by the Massachusetts Department of Mental Health. The guide lists the signs to look for when
doing an on‐scene assessment and includes detailed descriptions of early‐onset mental illness.
The guide can be accessed at www.ppal.net (Click “Publications” and “Police Pocket Guide”)
Training Video: Community Policing—Effective Response to Youth with Mental Illness
The Idaho Department of Health and Welfare developed a 30‐minute training video on
responding to youth with mental illness that relays scenarios police officers often encounter,
including youth suicide, a youth with bipolar disorder, and substance abuse. The video also
covers interpersonal skills and signs and symptoms of early‐onset mental illness. The Idaho
Department of Health and Welfare will also be implementing a three‐hour training for all first
responders that includes the video. The video and curriculum is available for purchase. Please
contact Stacie Golden, Training Specialist at The Idaho Department of Health and Welfare, at
goldens@dhw.idaho.gov or (208) 334‐0628 for more information.
School‐Based Resources and Programs
Center for Mental Health in Schools
www.smhp.psych.ucla.edu
Center for School Mental Health
http://csmh.umaryland.edu
Crisis Intervention Team Education Collaboration (CITEC)
The Portage County Mental Health and Recovery Board in Ohio has developed a crisis intervention
program for youth that focuses on school personnel. The program includes a 40‐hour crisis
intervention training for school staff, including teachers, administrators, guidance counselors,
and bus drivers. The training is modeled after the county’s adult CIT program for police, but includes
a number of modifications to make it more relevant and useful for elementary and high
school personnel. The program also promotes community collaborations and partnerships. For
24
more information about this program, contact Joel Mowrey, Ph.D., Associate Director, Mental
Health and Recovery Board of Portage County, at (330) 673‐1756 x203 or joelm@mental‐healthrecovery.
org.
National Center for Mental Health Promotion and Youth Violence Prevention
www.promoteprevent.org
Positive Behavioral Interventions and Supports
www.pbis.org

References
1 Interview with Keri Fitzpatrick, Manager, Colorado Crisis
Intervention Teams. November 5th, 2008.
2 Phone call with Sgt. Jon VanZandt, Adam County’s
Sheriff's Office. December 2nd, 2008.
3 Phone call with Carol Peters, Principal, Clear Lake Middle
School. December 16th, 2008.
4 Phone call with Terri Mabrito, Youth Diversion
Facilitator, The Center for Health Care Services.
November 24th, 2008.
5 Interview with Lt. Jeffry Murphy, Chicago Police
Department. November 6th, 2008.
6 Phone call with Stacie Golden, Training Specialist, Idaho
Department of Health and Welfare, and Oscar Morgan,
Ph.D., Technical Assistance Coordinator, Idaho
Department of Health and Welfare. November 25th,
2008.
7Ibid.
8 Phone call with Mo Canady, Training Director, National
Association of School Resource Officers. December 3rd,
2008.
9 National Center for Mental Health and Juvenile Justice.
Blueprint for Change: A Comprehensive Model for the
Identification and Treatment of Youth with Mental
Health Needs in Contact with the Juvenile Justice System.
2006.
10 Ibid.
11 U.S. House of Representatives Committee on
Government Reform, Incarceration of Youth Who Are
Waiting for Community Mental Health Services in the
United States, July 2004
12 New Freedom Commission on Mental Health, Achieving
the Promise: Transforming Mental Health Care in
America. Final Report. DHHS Pub. No. SMA‐0303832.
Rockville, MD: 2003.
13 Cohn. A. (2001) Positive Behavioral Supports:
Information for Educators. National Association of
School Psychologists. Retrieved February 3, 2009, from
www.nasponline.org/resources/factsheets/
pbs_fs.aspx
14 Wagner, M., Blackorby, J., & Hebbeler, K. (1993).
Beyond the report card: The multiple dimensions
of secondary school performance of students with
disabilities. Menlo Park, CA: SRI International.
15 U.S. Department of Health and Human Services. Mental
Health: A Report of the Surgeon General. Rockville,
MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of
Mental Health, 1999.
16 Ibid.
17 Ibid.
18 U.S. Department of Education, Twenty‐third annual
report to Congress on the implementation of the
Individuals with Disabilities Education Act, Washington,
D.C., 2001.
19 Rush, S. Improving Education for Students with
Emotional Disturbance. Knowbility. Retrieved February
3, 2009, from www.knowbility.org/research/?
content=improve
20 Wagner, M. (1995). Outcomes for youths with serious
emotional disturbance in secondary school and early
adulthood. The Future of Children: Critical Issues for
Children and Youths, 5(4), 90‐112.
21 Wagner, M., Blackorby, J., & Hebbeler, K. (1993).
Beyond the report card: The multiple dimensions
of secondary school performance of students with
disabilities. Menlo Park, CA: SRI International.
22 National Strategy for Suicide Prevention: Goals and
Objectives for Action. Rockville, MD: U.S. Dept. of
Health and Human Services, Public Health Service,
2001.
23 U.S. Department of Health and Human Services.
Mental Health: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of
Mental Health, 1999.
24 National Center for Mental Health and Juvenile Justice.
Blueprint for Change: A Comprehensive Model for the
Identification and Treatment of Youth with Mental
Health Needs in Contact with the Juvenile Justice
System. 2006.
26
25 Wagner, M. (1995). Outcomes for youths with serious
emotional disturbance in secondary school and early
adulthood. The Future of Children: Critical Issues for
Children and Youths, 5(4), 90‐112.
26 For more information about the Models for Change
project in developing a national CIT for Youth program,
please visit www.modelsforchange.net.
27 U.S. Department of Health and Human Services.
Mental Health: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Services
Administration, Center for Mental Health Services,
National Institutes of Health, National Institute of
Mental Health, 1999.
28 Mancini, P. (2008, November 4). Cultural Competence in
Behavioral Health: A CIT Approach. Presented at the
Crisis Intervention Team National Conference in
Atlanta, Georgia.
29 Steadman, H., Deane, M.W., Borum, R., & Morrissey, J.
(2001). Comparing outcomes of major models of police
responses to mental health emergencies. Psychiatric
Services, 51, 645‐649.
30 Sheridan, E., & Teplin, L. (1981). Police referred
psychiatric emergencies: advantages of community
treatment. Journal of Community Psychology, 9, 140‐
147
31 TAPA Center for Jail Diversion. (2004). What can we say
about the effectiveness of jail diversion programs for
persons with co‐occurring disorders? The National
GAINS Center. Accessed December 19, 2007, from:
www.gainscenter.samhsa.gov/pdfs/jail_diversion/
WhatCanWeSay.pdf
32 Ibid.
33 Compton, M., Esterberg, M., McGee, R., Kotwicki, R., &
Oliva, J. (2006). Crisis intervention team training:
changes in knowledge, attitudes, and stigma related to
schizophrenia. Psychiatric Services, 57, 1199‐1202.
34 Strauss, G., Glenn, M., Reddi, P., Afaq, I., et al.(2005).
Psychiatric disposition of patients brought in by crisis
intervention team police officers. Community Mental
Health Journal, 41, 223‐224.
35 Teller, J., Munetz, M., Gil, K. & Ritter, C. (2006). “Crisis
intervention team training for police officers
responding to mental disturbance calls.” Psychiatric
Services, 57, 232‐237.
36 Dupont, R., Cochran, S., & Bush, A. (1999) Reducing
criminalization among individuals with mental illness.
Presented at the U.S. Department of Justice and
Department of Health and Human Services, Substance
Abuse and Mental Health Services Administration
(SAMHSA) Conference on Forensics and Mental Illness
in Washington, D.C.
37 Bower, D., & Pettit, G. (2001). The Albuquerque Police
Department’s Crisis Intervention Team: A Report Card.
FBI Law Enforcement Bulletin 70(2), 1‐6.
38 Dupont R., & Cochran, S.(2000). “A programmatic
approach to use of force issues in mental illness
events.” Presented at the U.S. Department of Justice
Conference on Law Enforcement Use of Force,
Washington, D.C., May 2000.
39 Borum, R., Deane, M.D., Steadman, H., &
Morrissey, J. (1998). Police perspectives on
Responding to mentally ill people in crisis:
perceptions of program effectiveness. Behavioral
Sciences and the Law, 16, 393‐405.
27
2107 Wilson Boulevard, Suite 300
Arlington, VA 22201‐3042
Ph: (703) 524‐7600 ● Toll Free: (800) 950‐6264
Web site: www.nami.org

Mental health study: Income inequality, no respect, justice drives us nuts

By Sam Pizzigati

Editor, Too Much

WASHINGTON—Many Americans, says new polling from the Pew Charitable Trusts, don’t see inequality as a particular problem so long as society offers everyone an “opportunity” to get ahead. These Americans just might feel a bit differently if they had a chance to chat with the analysts behind a stunning new survey of the latest global research on mental health.

Mental Health, Resilience and Inequalities, prepared for the World Health Organization European Office by Dr. Lynne Friedli, in conjunction with the Mental Health Foundation, London, reports that income inequality may be driving people nuts.

Back in the 19th century, amid choking levels of infectious disease, scientists and eventually political leaders came to realize sewers and clean water could actually keep people healthy far better than any medical potion. Now here in the 21st century, amid the scourge of heart disease and other degenerative conditions, we may once again be poised for another great conceptual leap. We still, of course, need those sewers and that clean water. But we need something else, suggests this new report. We need respect and justice.

That’s not a message we normally expect to hear from mental health professionals. We tend to think about mental health, after all, as a matter of individual pathology — and we tend to separate mental from physical health.

The distinguished mental health professionals behind this report don't make that separation. They link mental health to the diseases that ravage our physical health — and tie both mental and physical health to levels of social and economic injustice.

Our “individual and collective mental health and wellbeing,” as Mental Health, Resilience and Inequalities pronounces, “depends on reducing the gap between rich and poor.” Read that sentence again, and think about its implications.

The British Mental Health Foundation backs this pronouncement up by walking us through a wide-ranging array of recent international medical research. “People with mental health problems,” research tells us, “have much higher rates of physical illness.”

Smoking, most of us understand, increases the risk of suffering cardiovascular disease. But researchers have documented that “the absence of positive mental health” will put you at greater risk for cardiovascular disease than smoking.

Mind over matter? Stress over immune system might be a better formulation. Chronic stress beats down our body’s defenses, upsets our physiological balances, leaves us open to disease.

What stresses us? Living in poverty, for starters. Coping with deprivation and disadvantage, day in and day out, wears us out. But stress doesn’t just come from eprivation, trying to make do without the material basics of life. Stress comes,

perhaps even more powerfully, from inequality, from the constant pressures that come with life in deeply divided societies, the foundation-backed report says.

“The adverse impact of stress is greater in societies where greater inequalities exist, and where some people feel worse off than others, it adds.” This stress impacts everyone, not just the poor. Deep-seated inequality heightens status competition and status insecurity across all income groups and among both adults and children.”

The reverse also holds. The smaller a society’s economic divides, the less stress, the more health.

“Both high and low income populations,” points out Mental Health, resilience and Inequalities, “benefit in more equal societies.”

This Mental Health Foundation analysis goes on to detail how the dynamics of unequal societies play out, with a level of medical specificity readers outside the health professions may sometimes have trouble digesting. But if your eyes don’t glaze over when the discussion turns to “C-reactive proteins,” you’ll have no trouble navigating your way.

And even those of us who stumble over “neuroendocrine” pathways and “bio markers” will find plenty of value — and even inspiration — in these pages. We can become more healthy, the Mental Health Foundation reminds us, because we can become more equal.

“This is not about utopian visions,” the foundation sums up. “The comparison between Sweden and the United Kingdom shows that relatively small differences in levels of inequality can have very significant effects on health.”

Courtesy of Labor World, April 1, 2009

Lakeville, Minnesota police unit trained to help the mentally ill

Crisis-intervention team is trained to help mentally ill

By Jessica Fleming
jfleming@pioneerpress.com

Updated: 05/09/2009 11:45:48 PM CDT

The woman lost her job.

She had a history of drinking, and that night, she drank too much, had a fight with her boyfriend and disappeared. Her boyfriend told police he feared she might hurt herself.

Some police officers might have shrugged off the call. Not officer Todd Williams.

Williams is part of Lakeville's Crisis Intervention Team, officers trained to help mentally ill residents — even if they have just committed a crime.

Calls like this one, Williams and Lakeville Police Chief Thomas Vonhof said, are increasing as the economy declines.

"If you don't have health insurance and you don't have money coming in, prescriptions are not cheap," Williams said. "Do you pay for your mortgage or do you buy your medicines?"

Williams eventually found the woman, who insisted she was OK. He referred her to Dakota County's Crisis Response Unit, which ultimately decided she wasn't a suicide threat. He credits the crisis team with helping to resolve the case quickly and peacefully despite the strains on the people involved.

"The stress of the economy definitely had something to do with it," Williams said.

Lakeville has nine Crisis Intervention Team members on its force of 51 sworn officers. Williams responds to several crisis calls a month.

Williams, 36, trained with the program when he was a Minneapolis police officer. He has been with the Lakeville force the past four years.

Minneapolis formed its Crisis Intervention Team in 2000 after several police confrontations with mentally ill people ended in shootings, said spokesman Sgt. William Palmer. Palmer, a member of the crisis team, was one of two officers who shot and killed Barbara Schneider as she waved a knife at officers in 2000. Schneider was mentally ill.

Shortly after her death, department officials traveled to Memphis to look at that city's crisis-intervention program and adopted the training that year, Palmer said. As many as 150 of Minneapolis' 890 police officers are now part of the team.

"We really didn't have adequate training prior to bringing CIT here," Palmer said. "Nothing's perfect, but I certainly think we're having better outcomes now."

The officers learn tools for approaching mentally ill people without further upsetting them. The most important thing, Williams said, is to approach slowly and calmly — the opposite of the assertive demeanor cops generally use to intimidate a suspect.

Tactics officers learn in the training include:

· Don't take control if you don't have to.

· Listen to the person's story.

· Don't argue or reason with psychotic thinking.

· Give the person space — don't make them feel trapped.

· Avoid quick or sudden movements.

Williams said crisis calls often require a lot of patience — which is why the program is voluntary.

"We spend a lot of time trying to gain a person's trust," Williams said. "A crisis call can take four or five hours. The absolute last resort is to physically make them go to a hospital."

On a recent call, Williams said, officers confronted a man who had hit another man with a metal shoehorn. When officers arrived, the man was delusional, talking about people shooting rays into his house, trying to collect information from him.

"When we contacted him, we didn't try to handcuff him or detain him like we'd do in a regular assault," Williams said. "We were afraid that if we tried to go the traditional route, it would have escalated things."

The officers eventually talked the man into going to the hospital.

The team does what it can to keep life from being more difficult for mentally ill people than it needs to be, he said. Eventually, the goal, along with protecting the public, is ensuring people will mental illnesses "get the help they need," Williams said.

Jessica Fleming can be reached at 651-228-5435.

State of Minnesota Takes Strides in Developing Crisis Intervention Training

The Adult Mental Health Division provided grants to the Adult Mental Health Initiatives in July 2008 to implement or enhance Crisis Intervention Teams (CIT) in their regions. Crisis intervention team
training provides police officers with knowledge and skills to improve their responses to individuals with mental illnesses.

Developing CIT is critically important since officers are often first-line responders to emergency calls involving individuals with mental illnesses. CIT was first developed in 1988 by the Memphis
Police Department in partnership with the Memphis chapter of the National Alliance on Mental Illness, the University of Memphis, and the University of Tennessee. CIT programs, through de-escalation
training and education about mental illnesses, have been successful in reducing unnecessary arrests and use of force, while increasing referral rates to emergency health care. Studies also show that compared with non-CIT officers from the same police department, CIT officers are significantly more likely to
feel well prepared in handling crises involving people with mental illnesses.

Grants have been awarded for one or more of the following core components of CIT to nine of the Adult Mental Health Initiatives in Minnesota: 1. Introduction to CIT through CIT Orientation meetings.
2. CIT Planning, Implementation & Networking facilitated meetings. Community collaborations and partnerships are essential to succesful implementation of CIT. 3. Dispatch training sessions to provide
training for emergency dispatchers such as call takers, dispatchers, and 911 operators. 4. Law Enforcement Officer Trainings. The 40-hour comprehensive training emphasizes mental health-related topics, crisis resolution skills, de-escalation training, and access to community-based services.

The Adult Mental Health Initiatives participating in developing CIT components with grants through June 2009 are: 1. NW8 - Polk County Host (& Kittson, Roseau, Marshall, Pennington, Red Lake, Norman, Mahnomen). 2. Region 2 – Hubbard County Host (& Lake of the Woods, Beltrami, Clearwater).
3. BCOW and 4 South –Grant County. Host (& Becker, Clay, Otter Tail, Wilkin, Traverse, Douglas, Stevens, Pope). 4. Region 7 East - Isanti County Host (& Mille Lacs, Kanabec, Pine, Chisago).
5. CommUNITY- Benton County Host (& Stearns, Benton, Sherburne, Wright) 6. Ramsey County.
7. South Central Community Based – Blue Earth County (& Sibley, Nicollet, Brown, LeSueur, Rice, Watonwan, Faribault/Martin, Freeborn). 8. SW 18 – Cottonwood County Host (& Big Stone, Swift, Kandiyohi, Meeker, Lac qui Parle, Chippewa, Renville, McLeod, Yellow Medicine, Lincoln, Lyon, Murray, Redwood, Pipestone, Rock, Nobles, Jackson). 9. CREST – Olmsted County Host (& Goodhue, Wabasha, Winona, Houston, Waseca, Steele, Dodge, Mower, and Fillmore).

Article Courtesey of NAMI-MN

Mental HealtH Services are key to cit success

A rigorous study of the Crisis Intervention Team in Chicago indicates the importance of “responsive and effective” mental health services to the success of CIT, a widely adopted, award-winning community policing program that has been shown to prevent injuries to police officers as well as civilians. The study, by researchers at the University of Illinois, Chicago (funded by the National Institute of Mental Health), found that “[c]ompared to their non-CIT trained peers, CIT trained patrol officers were resolving a greater proportion of calls by transporting or otherwise directing adults with mental illnesses to mental health services.” However, the researchers say that, unless the mental health services that receive officer referrals are “responsive and effective” and there are accessible supportive services, such as housing, employment, and medical care, “it is possible that officers (CIT trained or not) eventually may become disillusioned and stop making the effort to link people.” A policy brief about the study was published by the Rutgers University Center for Behavioral Health Services & Criminal Justice Research.

Source: http://www.cbhs-cjr.rutgers.edu/pdfs/Policy%20Brief%202%2009%20(2).pdf

View ...

Mental Illness alone not a trigger for violence

Combination of factors drive up danger, researchers say

By Carla K. Johnson, Associated Press
In the Pioneer Press, St Paul Minnesota

CHICAGO — A new large study challenges the idea that mental illness alone is a leading cause of violence. Researchers instead blame a combination of factors, specifically substance abuse and a history of violent acts, that drives up the danger when combined with mental illness in what they call an "intricate link."

People with serious mental illness, without other big risk factors, are no more violent than most people, according to the study of more than 34,000 U.S. adults. The research was released Monday in Archives of General Psychiatry. "Mental illness can provide the knee-jerk explanation for the Virginia Tech shootings," but it's not a strong predictor of violence by itself, said lead author Eric Elbogen of the University of North Carolina at Chapel Hill School of Medicine.

Elbogen compiled a "top 10" list of things that predict violent behavior, based on the analysis.

Youth topped the list. History of violence came next, followed by male gender, history of juvenile detention, divorce or separation in the past year, history of physical abuse, parental criminal history and unemployment in the past year. Rounding out the list were severe mental illness with substance abuse and being a crime victim in the past year. After the 2007 Virginia Tech killings by a student ordered to get psychiatric treatment, some states considered laws adding mental health questions to background checks for gun buyers or denying weapons to people who've been involuntarily committed for mental health treatment.

The new research, which bolsters other similar findings, raises questions about such laws, experts said. Such legislation may be both ineffective and discourage people who need help from getting treatment.

"We are being misled by our own fears," said Columbia University psychiatry professor Dr. Paul Appelbaum, who wasn't involved in the new study. "We ought to be concerned about providing good treatment and helping people lead fulfilling lives, not obsessed with protecting ourselves from phantom threats that appear to be unrelated to mental illness." U.S. systems to treat mental illness and substance abuse are separate, uncoordinated and could do a better job treating people with both problems, Appelbaum said.

For the new study, the researchers analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions. The original survey in 2001-2002 involved more than 43,000 face-to-face interviews with a representative sample of American adults. Three years later, many of the same people, more than 34,000, were interviewed again. From the responses, the researchers determined what elements raised the risk of violent behavior.

There were 3,089 people deemed to have severe mental illness — schizophrenia, bipolar disorder and major depression — but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10. The relationship between mental illness and violence is there, "but it's not as strong as people think," Elbogen said.

Back to the top

In dealing with the mentally ill
in jail, officials try a new way

By Rubén Rosario, St Paul Pioneer Press

I spent a few drama-filled hours in jail last week. A sobbing, suicidal inmate named "Christine" barricaded herself in her cell and refused to come out. Another inmate named "Mandy" did likewise in another cell on the same floor; she requested medical care as she showered jail officers with the kind of crude and sexually tinged language that would make even a street pimp blush. And four floors below in the basement, where the old-but-still-functioning jail operates under the arguably more stately and civil Minneapolis City Hall, a clearly agitated inmate named "Michael" held a physician hostage in a locked room.

"I'm not going to hurt him. I just need new medication," the hostage taker bellowed to a sweaty-palmed-but-composed jail negotiator on the other side of the locked door. Luckily, this was all theater. The inmates were local professional actors taking part in the role-playing portion of a four-day crisis-intervention team (CIT) training session put on by the Barbara Schneider Foundation. The Twin Cities-based nonprofit is named after a mentally ill woman fatally shot by Minneapolis police during a standoff in her apartment in June 2000. But the best art, in my view, imitates raw reality. In recent decades, America's jails and prisons have become the largest psychiatric hospitals and the repositories of last resort for mentally ill offenders. Mental illness is a brain disorder and not a crime, but we have chosen, largely because of ignorance and short-term convenience, to arrest and incarcerate this social problem.

According to studies and national statistics, about one of every four inmates in U.S. jails and prisons suffers from a mental illness. The breakdown is roughly the same with Minnesota's jail and prison populations. Corrections officials struggle to deal with mentally ill inmates amid escalating medical costs and dwindling budgets. Meanwhile, on the streets and inside homes, too many confrontations end up like Schneider's.

In 1998, just two years earlier, Americans with severe mental disorders were shot and killed by police at a rate nearly four times as great as that of the general population. The fear of harm, from a public-safety and officer-safety point of view, may have been justified: That same year, mentally ill Americans killed law enforcement officers at a rate 5.5 times higher than the general population did. National crisis? No doubt. But what to do?

CHANGING TACTICS

The response in places like Minnesota has been: Raise awareness. Change the mind-set. Cut through the entrenched cultural stigma about the mentally ill without sacrificing officer safety. Embrace de-escalation techniques while toning down the traditional law-and-order use-of-force continuum with this population. Is it working?

Hennepin County Sheriff's Lt. Randy Carroll, an 18-year veteran and training-session coordinator, says use-of-force incidents — in which officers physically subdue or restrain inmates — have plunged 40 percent in the county jail in the two years since the training was introduced. The jail books nearly 43,000 people annually, by far the most in the state.

About 70 percent of those inmates are repeat offenders, and a "good percentage of them are mentally ill to some degree," said Hennepin County Sheriff Rich Stanek, the former Minneapolis cop and state legislator who was elected sheriff two years ago.

"We can either serve as just a warehouse or try to do something far more innovative that addresses the root cause of the problem," said Stanek, adding that the jail has added facilities to house and care for such inmates. "This is absolutely all about de-escalation," Stanek said. "We are in a place where, to the inmate, there really is no place to run to or go. So there really shouldn't be a reason, other than an officer-safety or hostage crisis, where we need to use force to solve an issue."

SPREADING THE WORD

The participants in last week's training included jail officers from metro and outstate counties. Dave Isais, a Sherburne County jail captain and nearly nine-year veteran, was thrown into the unfolding hostage simulation.

"I'm sure the doctor is pretty scared right now," Isais told inmate "Michael." "I know you didn't mean to do anything," he added. "Could you let him come over here so we can talk about medication that could help you? Would you be willing to come with me to another room?"

Isais, who shook hands with me and apologized because his was moist from the role-playing encounter, got high marks from Josh Fulwider, a CIT-trained Hennepin County deputy. "The thing I want to stress to you is that in this type of action, there are no limits to what you can say," Fulwider told him during a break.

"You can say whatever," Fulwider added. "If it's something that's from the training that you received or something you saw in the news, you can use it. Use it to let them understand that you are paying attention and that you care about people."

In an earlier scenario, Mark Anderson, executive director of the Barbara Schneider Foundation, underscored the hesitancy and fear that jail personnel have about bringing up the issue of mental illness during such incidents. "You are not the first person that has ever asked them this," Anderson counseled one group. "They are used to talking about it."

Moments earlier, before Isais was thrust into the mock hostage crisis, a veteran Washington County correctional officer gently tried to coax inmate "Christine" out of a barricaded holding cell. It could have easily been done with force. Roosevelt Collins instead applied verbal judo dripping with empathy and concern.

"You went from '(Expletive) you' to 'My name is Christine' to getting her to open up and reveal stuff to you," said Chris Mays, a CIT-trained Hennepin County deputy monitoring the role-playing segment. "I think you did a really good job. If you had another 20 minutes, I think you would have gotten her."

"I learned a lot," Collins told me and others during a break. So did I.

Rubén Rosario can be reached at rrosario@pioneerpress.com or 651-228-5454.

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When a desperate teen in Shoreview
met a good cop who wouldn't give up

By Rubén Rosario, St Paul Pioneer Press

There is a ton of bad as well as good public servant stories out there. This is one of the really good ones.

Ramsey County Sheriff's Deputy Mike Casey briefly considered following the routine when 15-year-old Jani Ray of Shoreview was reported as a runaway: Question the parents or legal caretakers. Jot down the basics. File the report. Resume patrol.

Instead, he took the time on an early spring day this year to read a computerized field note, known as an "FI," that informed him about the runaway youth's bipolar disorder, depression and other mental afflictions.

It confirmed his gut instinct. Routine just would not do this night.

He found her MySpace account. In it, he read disturbing writings — words that hinted at thoughts of suicide. He combed through her cluttered bedroom with her mother's permission and found journals her mother never knew existed, journals that expressed similar, dark thoughts.

He spent much of that unusually slow Saturday night looking for her.

On Wednesday, Casey and Jani Ray saw each other for the first time since the runaway episode. Along with her mother, Nancy Ray, the youth presented Casey with a St. Michael the Archangel medallion. St. Michael is the patron saint of cops.

"I would like to see him in person and would love to thank him face to face," Jani Ray told me a few days before the reunion. "If he wouldn't have come and got me that night, I don't even think that I would be alive right now. I owe him my life." A recap is in order.

Nancy Ray, who works as a financial officer for Ramsey County's Human Services Department, approached Ramsey County Sheriff's Deputy Sgt. Kent Mueller, who works in the same government building in downtown St. Paul.

Ray's daughter was refusing to take her medication, she told the deputy. She was abusing drugs and alcohol. Ray feared the girl would likely run away again. She wondered if there was anything proactive she could do to alert authorities in the event Jani ran away or had a run-in with the law.

Mueller, trained in crisis intervention, serves on the board of the Barbara Schneider Foundation. The nonprofit is named after a Minneapolis woman who was fatally shot by police during a confrontation in her home in 2000. Although two officers were cleared of criminal wrongdoing in the shooting, Minneapolis established a special police crisis unit to respond to calls involving people with mental illness. The group trains first responders, from cops and emergency room staff to homeless and school officials, on how to de-escalate and deal with a mental-health crisis. It had just conducted a three-hour seminar for all Ramsey County sworn personnel.

Mueller suggested writing up a field note with information on Jani Ray's condition and state of mind. As predicted, Jani Ray ran away several days later.

"It was an option for me," Ray said now of her writings about suicide. "I truly felt alone. I felt like I had no one. I was willing to go the full hundred yards and end my life because I was very unhappy."

GETTING HELP

When Casey responded to the runaway call, Nancy Ray suggested he look up the field note on her daughter. Casey pulled it up in his squad car's computer. He tapped into Jani Ray's MySpace account and then went back into the home, where he found the journals and a list of cell phone numbers for several of the runaway teen's friends. He spent roughly two hours calling numbers, pretending to be "Mike," a friend. He learned that Jani Ray was expected to show up that night at a backyard house party in Shoreview. The girl having the party was a friend of Jani Ray, and she and her father agreed to help lure Ray to the home. When the runaway teen arrived, Casey and a female officer approached her. Playing tough cop at first, he grabbed her arm and told her she was coming with him. "She was very subdued, but she was in a dazed state," Casey said.

"I'm not going to arrest you. I'm going to take you home. We're going to get you some help," he remembered telling the teenager as she sat in the back seat of his car.

Jani Ray's admission that she had not taken her medication gave Casey the authority to take the teen to a medical facility and place a 72-hour hold on her. But he allowed Nancy Ray as the parent to do that. Jani Ray attended two intensive-treatment facilities from late spring until late August, when she was released in time for the start of classes at Mounds View High School. She confided to schoolmates for the first time about her situation.

"I was completely honest with them, and my peers have been unbelievably supportive of me," Ray told me during our chat inside the apartment she shares with her mother. "They want for me to be with them, to have a normal high school experience like them."

GOAL: SHARING INFO

Mueller believes field notes — which are not incident or full-fledged police reports — could be used by the law enforcement community to store critical information provided by relatives or others about the mental state or condition of someone they might come into contact with on the streets. Mental disorders are the leading cause of disability in the U.S. for persons ages 15 to 44, according to the National Institute for Mental health. Roughly one out of four Americans age 18 or older — close to 58 million people — suffers from a diagnosable mental illness in any given year.

"Knowledge is power," said Mueller, who is in the preliminary stages of finding out whether area police agencies are willing to share such information. Right now, Mueller said, such field notes cannot be shared because of different and incompatible police data computer systems.

Mueller envisions the day when every police agency in the state, if not the country, shares field notes. But the reality is that few police agencies have compatible computer systems to tap and view such data right now. Casey, meanwhile, had no clue about the impact he had that night until I gave him a jingle.

"Wow," he said. "It sounds cheesy, but I just simply wanted to find her and get her home, just for mom's sake." Jani Ray is willing to share her struggles publicly to help lift the stigma of mental illness among youths as well as hopefully to encourage troubled teens to seek help.

"I understand now that I was not alone, that there are caring people out there, my mother and others, who love and support me and that I can go talk to,"" Jani Ray said. "I needed to let this officer know just how much he means to me. There is not a day that goes by that I don't think about what he did."

"She can count on me if she ever needs to talk to someone," Casey said. The guardian angel medallion sounds like an appropriate gift after all.

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NAMI's Public Policy Position on
Tasers and Related Weapons

8.9 Application of Less Lethal Weapons
by Law Enforcement Officers

(8.9.1) The National Alliance on Mental Illness (NAMI) believes that the use of conducted energy devices (including stun guns, tasers, impact delivery systems, or any other similar non-firearm weapons)used by law enforcement officers responding to individuals with serious mental illness should be permitted only if the responding officer concludes that an immediate threat of death or serious injury exists, which cannot be contained by lesser means, and/or is likely to be hazardous to the officer(s), the individual, or a third party. Such devices should not be deployed when other means or methods of de-escalations are appropriate, available, and suitable for the crisis event, nor should these devices ever be used as a means of intimidation or inappropriate coercion.

(8.9.2) NAMI further believes that states should include, in statute, a requirement for the development and enforcement of standards and minimum training requirements for all law enforcement, corrections and other personnel who use or may potentially use these devices in the performance of their duties. This mandatory training must include information about effective methods of responding to people with mental illness in crisis with verbal and non-verbal crisis de-escalation techniques.

(8.9.3) States should also strictly define in statute categories of professionals who are authorized to use these devices in the performance of their duties and should strictly prohibit usage of these devices by those not identified as authorized users in statute.

(8.9.4) NAMI calls upon the states and the federal government to fund and promote research that documents the incidence of use of these devices and investigates both the short term and long term physical and psychological impact on people who have experienced the application of such devices. This research also should determine the potential dangers associated with risk factors, including but not limited to age and pre-existing medical conditions.

(8.9.5) Each use of these devices should be investigated by the respective law enforcement agency or institution in the same way that use of a firearm would be investigated by a law enforcement agency.

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Cops and the Mentally Ill

By Eugene O'Donnell | Newsweek Web Exclusive

Barely concealing his anger, Chaplain Thomas Nangle told an overflow funeral mass for Chicago policeman Richard Francis that the 60-year-old officer did not give his life in the line of duty—rather, it was "taken" from him.

Days before, on July 2, Francis, a 27-year veteran of the force, responded to a call steps from the police station where he was assigned. An emotionally disturbed person—EDP in police parlance—had fought with another passenger on a city bus. Before Francis could calm the woman, she grabbed his gun and shot him in the head. All too predictably, family members of the woman, Robin Johnson, told reporters that they had tried to get the woman help as her life slipped downhill.

From coast to coast, mentally ill people, without reliable access to the costly on-demand care they need, are left to fend for themselves. In the aftermath of the movement in the 1970s to close large mental asylums, many of today's mentally ill are left to their own devices; they are often homeless and without full-time advocates. With government unable or unwilling to properly serve this population, the criminal-justice system is left to pick up the slack.

Contrary to what many assume, the mentally ill are most often the victimized, not the victimizers. A 2005 study by researchers at the Feinberg School of Medicine at Northwestern University suggested that persons with serious mental illnesses are 11 times more likely than the general population to be victims of violent crime, with perhaps as many as 1 million crimes committed against those with serious mental-health issues each year.

But relying on the police to address the problem has too often resulted in tragedy, not only on the mean streets of big cities but in quieter places as well. In Silverton, Ore. (population, 7,500), a 20-year-old Irish immigrant, Andrew Hanlon, described by friends and family as suffering from paranoia and delusions, was shot and killed by a police officer investigating a report that Hanlon was trying to break into a residence on June 30. The officer who shot Hanlon told a grand jury—which voted not to indict him—that he thought Hanlon had wielded a broken bottle. At a candlelight vigil attended by 100 people, friends of the deceased man questioned the use of deadly force, saying that the police should have known the man was more of a local character than an actual threat and that he was banging on doors, not trying to break into anyone's home. The killing drew international attention. The same cannot be said about the shooting death, nine days later, of a homeless, emotionally disturbed 40-year-old Newark, N.J., man, Francisco Martes, who was shot by police after allegedly waving a knife at an officer. This more "typical" EDP incident garnered little press coverage beyond the usual police-blotter report.

Experts on treatment say the police for the most part do a good job handling the millions of interactions they have each year with the mentally ill. But is it irresponsible to ask them to undertake duties that perplex even trained, savvy professionals? "The police are not meant to be street-corner psychologists," says Dr. Linda A. Teplin of Northwestern University, one of the authors of the 2005 report about mentally ill crime victims. She notes the chronic shortage of beds for the mentally ill in treatment facilities, something that results in fewer stays, shorter stays and the reality that "you have to be extremely mentally ill" to get one of them. There is also a pressing need for more housing for this population. For law enforcement, experts say more training and more nonlethal weapons such as the controversial Taser could be beneficial.

Following the deaths of two people in Rhode Island this year in separate encounters with police, Rep. Patrick Kennedy secured a grant of $200,000 to enhance police training for responding to the mentally disturbed. After a third person, a man in police custody, died, Kennedy called for the creation of a statewide crisis-intervention team that would be available to handle cases of emotionally disturbed individuals.

Pressured by media coverage about mentally ill people committing serious crimes, New York city and state officials recently acknowledged major failings in mental-health care and oversight and in the exchange of information between mental-health providers and law enforcement. A task force recommended training New York Police Department dispatchers, who handle roughly 90,000 calls annually regarding the emotionally disturbed, to ask better questions so that the officers responding have more information.

The task force also called for the creation of a location database with call histories involving the mentally ill so that specially trained emergency-service officers can be dispatched more expeditiously. Another proposal: to establish Mental Health Care Monitoring Teams in New York City, which would help coordinate and track the care of high-need clients. According to the New York Daily News, $13 million will be spent to create a sophisticated tracking system that will improve the continuity of mental-health care, identify when individuals requiring care cease treatment and speed up interventions for high-risk people when, for example, they stop taking anti-psychotic medications.

And New York plans to expand its use of mental-health courts and to share information from the tracking system with criminal-justice agencies to improve treatment of mentally ill individuals who are arrested. Civil-liberties groups are watching warily to make sure that the information collected by the database does not end up being used against mentally ill defendants.

The New York report cited the "struggle" that facilities are faced with in treating tens of thousands of mentally ill persons under correctional supervision. Thomas Faust, the former executive director of the National Sheriffs' Association, has said that the large growth in many correctional facilities is due to a lack of mental-health resources. The three largest de facto mental-health facilities in the country, he wrote in 2003, are actually jails: "Riker's Island (in New York City), Los Angeles County and Cook County [in Chicago]." An estimated one in five prisoners in these facilities receive or require daily mental-health attention—treatment they would likely be denied in the outside world.

According to a 2000 report by the federal government's National Institute of Justice, once a mentally ill person is arrested for disorderliness, that person is labeled a "criminal" and will likely continue to be arrested when acting out in the future, rather than receive treatment.

In a presidential-election year featuring a Republican candidate who prides himself on straight talk and a Democrat who suggests the nation adopt a new can-do ethos, perhaps there is a glimmer of promise that the dialogue on criminal justice this fall can extend past the archetypical embrace of blame and "toughness" and examine the 50-state crisis in mental-health care. On the streets, there is hard work to be done.

O'Donnell is a professor of police studies and law at John Jay College of Criminal Justice in New York City.

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Crisis Intervention Team Training
for Police Officers Responding to Mental Disturbance Calls

By Jennifer L. S. Teller, Ph.D., Mark R. Munetz, M.D.,
Karen M. Gil, Ph.D. and Christian Ritter, Ph.D.
Psychiatr Serv 57:232-237, February 2006
doi: 10.1176/appi.ps.57.2.232
© 2006 American Psychiatric Association

Abstract

OBJECTIVES: In recognition of the fact that police are often the first responders for individuals who are experiencing a mental illness crisis, police departments nationally are incorporating specialized training for officers in collaboration with local mental health systems. This study examined police dispatch data before and after implementation of a crisis intervention team (CIT) program to assess the effect of the training on officers' disposition of calls.
METHODS: The authors analyzed police dispatch logs for two years before and four years after implementation of the CIT program in Akron, Ohio, to determine monthly average rates of mental disturbance calls compared with the overall rate of calls to the police, disposition of mental disturbance calls by time and training, and the effects of techniques on voluntariness of disposition.
RESULTS: Since the training program was implemented, there has been an increase in the number and proportion of calls involving possible mental illness, an increased rate of transport by CIT-trained officers of persons experiencing mental illness crises to emergency treatment facilities, an increase in transport on a voluntary status, and no significant changes in the rate of arrests by time or training.
CONCLUSIONS: The results of this study suggest that a CIT partnership between the police department, the mental health system, consumers of services, and their family members can help in efforts to assist persons who are experiencing a mental illness crisis to gain access to the treatment system, where such individuals most often are best served.

Introduction

Police officers are recognized as first responders for individuals who are experiencing a mental illness crisis (1,2,3,4). In the absence of specialized training in mental illness and knowledge about the local treatment system, such crises may end in arrest and incarceration when referral and treatment might be more appropriate (5,6). The absence of collaboration between law enforcement and mental health systems has been posited as one factor in the emergence of the complex phenomenon known as the criminalization of persons with mental illness (7,8,9).

Partnerships between law enforcement and mental health systems may address this problem. One such collaboration is the crisis intervention team (CIT) model, started in 1988 by the Memphis Police Department (10). The CIT program provides intensive training about mental illness and the local system of care to patrol officers, who then are available to respond to mental disturbance calls. The idea has spread nationwide, and approximately 70 departments have formed their own CIT programs (personal communication, Cochran S, October 9, 2004).

Although clearly intended to increase officers' skills in deescalation of crises among persons with mental illness, CIT partners may seek different—although complementary—outcomes. Law enforcement may be most interested in improving the safety of both officers and consumers during potentially dangerous encounters, whereas mental health may focus more on decreasing inappropriate arrests of persons with mental illness.

In this article, we examine disposition of mental disturbance calls before and after implementation of one city's CIT program. The purpose of the study reported here was to determine whether CIT-trained officers were more likely than non-CIT-trained officers to respond to calls involving individuals with mental illness who were experiencing a crisis by transporting the person to a health care facility and less likely to either arrest the person or leave the person at the scene. Furthermore, for cases in which an officer determined that transportation to a treatment facility was necessary, we examined whether the transportation to treatment was voluntary or involuntary, by officers' CIT training status.

The program in Akron, Ohio, began in May 2000 with the collaboration of the Akron Police Department; the Summit County Alcohol, Drug Addiction, and Mental Health Services Board and its provider agencies; the National Alliance for the Mentally Ill (NAMI) of Summit County; the Summit County Recovery Project; and the Northeastern Ohio Universities College of Medicine (NEOUCOM). Two major modifications were made to the Memphis program to account for differences in services available. Akron, unlike Memphis, has a freestanding psychiatric emergency service, which means that individuals who have a comorbid nonpsychiatric medical condition may be referred to a general hospital emergency department instead of or before going to psychiatric emergency services. In addition, Akron's emergency medical services dispatch a paramedic unit to emergency calls identified as involving persons with mental illness. In general, emergency medical services are in charge of nonpsychiatric medical calls, and the police are in charge if a call is due primarily to manifestations of mental illness without comorbid medical complications. As a result, paramedic lieutenants from the Akron Fire Department were included in initial training.

The first weeklong training occurred in late May 2000 with 20 Akron police officers and three paramedic lieutenants from the Akron Fire Department. All officers were volunteers and were screened by the training director to determine their appropriateness for this team of officers who were most likely to encounter individuals experiencing mental illness crises. Communication skills and being self-motivated to improve skills and knowledge about mental illness were the prime selection criteria for the program. Officers received a 40-hour introduction to mental health and mental illness with an intensive overview of the local mental health system and its points of access. Officers visited psychiatric emergency services, went into the community with case managers, and visited a consumer-directed social center. They received extensive training in verbal deescalation skills and engaged in realistic role playing to practice these skills in simulated crises at the NEOUCOM Center for the Study of Clinical Performance. Officers were encouraged to consider, when appropriate, linkage and referral for care to the mental health system as a preferable alternative to arrest.

CIT-trained officers began patrolling in the Akron community on May 27, 2000. Training was provided annually for new team members. Excluding officers who have been promoted or have retired, currently 66 of 243 active patrol officers (27 percent) are CIT trained (personal communication, Yohe M, July 29, 2004). In addition to training for officers as detailed above, refresher training sessions have been held annually since 2003. These sessions are for supplementary mental health training and to identify areas in program implementation where difficulties exist for officers and the people they serve. Modified annually, the two-day refresher course has included updates on legal and medical issues, research results, advanced techniques in negotiation and suicide prevention, and taser techniques, procedures, and qualification.

CIT officers handle situations they encounter on patrol or through dispatch. Dispatchers evaluate emergency calls and have two codes for mental disturbance calls: suspicion of mental illness and suicide attempt in progress. Once on the scene, responders may determine that the call does not involve a person with mental illness. Conversely, other codes—for example, fights—may involve a person with mental illness but may not be coded by dispatchers as a call related to a mental disturbance.

Methods

We obtained institutional review board approval from all applicable agencies before beginning the project. Data were analyzed for the two years before and the four years after implementation of the CIT program by using SPSS, version 12.0. The Akron Police Department provided data on the number of calls for assistance. All calls that were coded as mental disturbance calls by police department dispatchers from May 1998 through April 2004 were made available to the research team. These calls included the call date, the time, whether CIT team members were present, police code corresponding to disposition of the call, and notes from the Akron Police Department and emergency medical services. Notes were evaluated to determine disposition location and information about which agency was in charge of the call (the Akron Police Department, emergency medical services, or another agency, such as the coroner, the local jail, or a mental health agency). Notes were consulted to determine whether the officer who transported the individual to a treatment facility initiated an involuntary commitment process.

The number of calls for assistance per month and the number of calls related to a mental disturbance per month were summed per year (May through April), and the rate of mental disturbance calls per 1,000 Akron police department calls per month was calculated. Analysis of variance (ANOVA) statistics were calculated. If the means were significantly different at the p<.05 level, one-way ANOVA Scheffé's post hoc tests were run to identify categories of difference. Compared with other tests, Scheffe's is a conservative estimate, because larger differences in means are required for significance.

Percentages and chi square statistics were calculated for the dispositions of calls by time and training. Time was dichotomized as either the two years before implementation of the program (May 1998 through April 2000) or the four years after (May 2000 through April 2004). Training was dichotomized as either CIT-trained or non-CIT-trained. Analysis of variance was calculated on the basis of disposition proportions. If the means were significantly different at the p<.05 level, Scheffé's post hoc tests were run to identify categories of difference.

Results

Proportion of mental disturbance calls
From May 1998 through April 2004, the Akron Police Department received 1,527,281 calls for service, of which 10,004 were related to mental disturbances. The average number of calls per month (21,212) was stable over the six-year study period (data not shown). The total number of calls per year increased slightly over the six years, although not significantly. The two years before implementation of the program and the year of implementation were significantly different from the last two years studied (p<.006). There was an absolute increase in the number of calls identified as mental disturbance calls and in the rate of calls related to mental disturbances per 1,000 calls for assistance (F=9.39, df=5, p.001) as well as a proportional increase (F=15.86, df=5, 66, p.001).

Disposition of calls for mental disturbances
Initially there were seven disposition categories: transport to psychiatric emergency services; transport to another treatment location, such as an area hospital or detoxification facility; transport to a jail; police interaction with no need for transport (for example, giving advice, assisting, or talking to the person); other transportation (including to a shelter or residence); no police interaction (for example, the officer was unable to locate the individual); and disposition unknown. Over the six-year period, almost 25 percent of the 10,004 mental disturbance calls resulted in transportation to psychiatric emergency services, and 31 percent resulted in transportation to local hospitals or another treatment facility. Thirty-two percent of the calls involved police interaction with no need for transport. Almost 3 percent of the calls resulted in an arrest. Slightly fewer than 8 percent resulted in no police interaction, and 2 percent involved some nontreatment transport; in less than .5 percent of the calls the disposition was undetermined.

We continued our analyses with four disposition categories: transport to psychiatric emergency services, transport to another treatment location, transport to jail, and police interaction with no transport. The other three categories were not analyzed, because these three disposition categories do not appear relevant to understanding police interaction with individuals who are mentally disturbed. Eliminating these categories decreased the sample size by about 10 percent to 8,985.

Disposition by officers' CIT training status
Table 1 is a cross-tabulation of the four disposition categories by time and training. After implementation of the program, the overall rate of transport to jail decreased slightly, from 3.0 percent to 2.9 percent. When we compared the two groups of officers after implementation of the program, CIT-trained officers were more likely than non-CIT-trained officers to have transported persons with mental disturbances to jail (4.1 percent compared with 2.4 percent), although the difference was not significant. When CIT-trained officers' interactions were compared with those of the other two groups, CIT-trained officers were also more likely to have transported persons with mental disturbances to psychiatric emergency services and less likely (although not significantly less) to have transported them to other treatment facilities. CIT-trained officers were also less likely to have interactions involving no need for transport than were other officers, either before or after implementation of the CIT program, but, again, the difference was not significant.

The fact that emergency medical services were in charge in the case of some of the calls may have masked the effects of training, because there may not be opportunities to use deescalation techniques in emergency settings. Table 2 shows dispositions by officers' CIT training status after removal of these nonpsychiatric medical calls (N=4,367). With these calls excluded, there was no longer a significant difference in arrest rates between the three groups, which suggests that training status did not affect arrests. However, CIT-trained officers were significantly more likely than either of the other two groups to take mentally disturbed persons to psychiatric emergency services and less likely to be involved in calls for which there was no need for transport. Compared with non-CIT-trained officers for the period May 2000 through April 2004, CIT-trained officers were significantly less likely to be involved in calls for which there was no need to transport the individual.

Before implementation of the CIT program, 10.6 percent of people who were transported for treatment were transported on an involuntary legal status. There was a significant decrease in the involuntariness of transport after implementation of the program for both non-CIT- and CIT-trained officers, as can be seen from Table 3.

Discussion

Since the CIT program began, there has not been an increase in the volume of all calls, but the absolute number of mental disturbance calls and the proportion of such calls have increased. We suspect at least two possible explanations for this increase in the number of calls related to mental disturbances after implementation of the CIT program. First, the dispatchers may have been more aware and better prepared to assess a call as involving a person with mental illness. Second, with the community's knowledge of the CIT program and the participation of NAMI, callers may have been more likely to acknowledge the involvement of a person with mental illness. Since the program began, family members have reported that they are more comfortable calling the police to request help for a loved one, and consumers of mental health services have reported calling the police to request help for themselves or their peers.

A number of findings suggest that the program is meeting the desired outcomes for both sides of the partnership. Compared with nontrained officers, trained officers are more likely to transport a person for treatment than they were before the program was implemented. Training effects may explain this difference, given that recognition of symptoms of mental illness and knowledge of options for treatment are part of CIT training.

The study showed that trained officers are less likely to end calls without arranging for transport of the person involved. This issue is complex. Police officers on the scene have considerable discretion (1,11). For officers in general, the less time-consuming course is to rule out an emergency and resolve the call without arranging transport. CIT-trained officers presumably appreciate the fact that timely intervention in the treatment system may prevent future emergencies, even if the situation at hand does not mandate transport. On the other hand, CIT-trained officers may use their training to deescalate and counsel individuals so that no further emergency intervention is needed. As CIT has evolved in Akron, the police and mental health systems have been developing outreach programs so that people who may not need emergency mental health intervention receive appropriate mental health follow-up. The effects of such programs on the rate of calls that do not involve the arrangement of transport remain to be seen. At this point, however, it appears that the significant difference in the rate of calls that did not involve transport between CIT-trained and non-CIT-trained officers reflects a desired outcome.

We cannot explain with certainty the observation that after implementation of the CIT program there was a decrease in involuntary transports for both CIT- and non-CIT-trained officers. It may be that the emphasis during training on use of verbal deescalation techniques to avoid escalation of crises filtered throughout the department, or it may be that CIT-trained officers are referred the more challenging cases, which could mask the effects of training. In any case, all stakeholders perceive this outcome as a positive one.

The apparently higher rate of arrest by CIT-trained officers was unanticipated. Mental health systems support CIT programs in part because they view the programs as prearrest diversion programs. Police agencies, on the other hand, embrace the CIT program as a means of enhancing officer and community safety. Through CIT training, officers may learn when referral to the mental health system is most effective and when arrest may be preferable. As noted above, it is possible that dispatchers are sending CIT officers to the most challenging mental disturbance calls, for which officers may have less discretion as to whether to arrest the individual. That this might be the case could be supported by the fact that the initially significantly higher arrest rate by CIT-trained officers disappeared and differences in significance between CIT-trained and other officer groups in both transport to other treatment and no need for transport appeared after calls handled by emergency medical services were excluded from the analyses. Emergency medical services handled 54 percent of calls attended by non-CIT-trained officers both before and after the CIT program was implemented but handled only 42 percent of calls attended by CIT-trained officers. Removal from the data of primarily nonpsychiatric medical calls, for which officers lack discretion about disposition, clarified the differences between the groups of officers. CIT-trained officers' arrest rates were not significantly different from those of the other officer groups, but the CIT-trained officers transported mentally disturbed individuals to treatment facilities more often.

Furthermore, it is likely that Akron arrest rates are influenced by officers' knowledge of the Mental Health Court postarrest diversion program. The Akron Mental Health Court began in January 2001, shortly after the start of the CIT program (12,13). This court is for misdemeanants with severe and persistent mental illness who receive intensive community-based treatment in lieu of incarceration. Court personnel participate in CIT training to explain the program and to encourage officers to refer the individuals they arrest to the mental health court. Knowledge of the program and the fact that it may help individuals who may otherwise be resistant to treatment to live successfully in the community may result in CIT-trained officers' choosing arrest in selected cases. The interaction of prearrest diversion programs such as the CIT program and postarrest programs such as the mental health court should be the subject of future research.

Given that these results are not based on experimental data, it is not possible to make causal assertions about the effects of police training on dispositions. That is, officers were not randomly assigned to training. Furthermore, officers were acting as their own controls by using the pre-CIT program as a comparison group. Ideally, we would have liked to have similar data from a community that did not have a CIT program as an additional comparison group. Despite these limitations, the findings are important.

In addition, future research should consider the effects of the circumstances surrounding the call. A complementary study that examined qualitative CIT-trained officers' field reports (manuscript in preparation) had similar findings, suggesting that although CIT programs may have a significant impact on police referral for treatment and decreased use of force and involuntary commitment, these programs may not reduce arrests of people with mental illness. Only a study of the circumstances of each arrested individual, the nature of the charges, and the officer's rationale for arrest will help explain these findings. Future examination of narrative reports on each CIT encounter will address these questions.

CIT programs require a partnership between law enforcement and mental health systems as well as consumers of mental health services and their families. Each stakeholder group may desire overlapping but somewhat different outcomes. It is likely that CIT programs will differ depending on the mental health and criminal justice systems' community resources. As data accumulate on the effectiveness of CIT programs, communities will need to decide whether the outcomes warrant the considerable investment in the program. If CIT enhances the safety of both officers and consumers but does not reduce the arrest rate, for example, will courts and jail administrators support it?

Conclusions

The implementation of a crisis intervention team (CIT) program for police officers has led to an increased number and proportion of calls recognized by police dispatch as potentially involving mental illness. Training has led to increased transport of persons who are experiencing a mental illness crisis to emergency evaluation and treatment facilities, and transport is more likely to be on a voluntary basis compared with officers who have not participated in the training. This finding suggests that the CIT partnership between the police department, the mental health system, consumers of services, and their family members can help in efforts to assist individuals who are experiencing a mental illness crisis and interacting with the criminal justice system to gain access to the treatment system, where such individuals most often are best served. The expected effects on arrest rates were not clearly demonstrated. Future research is needed to examine decisions to arrest and to understand the interactions between multiple programs such as CIT and mental health courts and to learn how different CIT program elements lead to desired outcomes.

Acknowledgments

This research was supported by the Ohio Department of Mental Health (grant 02.1176) and the Ohio Office of Criminal Justice Services (grant 2002-DG-C01-7068). The authors thank the following officers of the Akron Police Department for their assistance and patience: Lt. Michael Woody (Ret.), Sgt. Michael Yohe, Michael Carillon, Lt. Michael Prebonick, and Chief Michael T. Matulavich. The authors also thank the following students who assisted in data cleaning: Natalie Bonfine, Sue Drexel, Marcee Jones, Ashley Kilmer, Kris Kodzev, Marnie Salupo Rodriguez, Dana Sohmer, and Joyce Wall.

Footnotes

Dr. Teller and Dr. Ritter are affiliated with the department of sociology of Kent State University, Kent, Ohio 44242 (e-mail, jteller@kent.edu ). Dr. Munetz is with the Summit County Alcohol, Drug Addiction, and Mental Health Services Board in Akron, Ohio, and with the Northeastern Ohio Universities College of Medicine in Rootstown. Dr. Gil is with Akron General Medical Center and Northeastern Ohio Universities College of Medicine.

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The Akron Municipal Mental Health Court Mission Statementand Protocol. Akron, Ohio, Akron Municipal Court, 2001
The Akron Mental Health Court Sanctions and RewardsProgram, Akron, Ohio, Akron Municipal Court, 2001

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Co-occurring Disorders Program: Integrated Services for Substance Use and Mental Health Problems

Developed by faculty from the Dartmouth Medical School
Available from Hazelden Publishing, September 2008

An integrated system of mental health and addiction services that emphasizes continuity and quality is in the best interest of consumers, providers, programs, funders, and systems.
- Co-occurring Center for Excellence (SAMSHA)

In recent studies, researchers estimate that about half of the people treated in mental health settings have at least one substance use problem in their lifetime, if not within the past year. Approximately 25 to 33 percent of the people treated in mental health settings have experienced substance use problems either currently or within the past year. In addiction treatment settings, these estimates are similar if not higher. As many as 50 to 75 percent of people in addiction treatment centers also suffer from a psychiatric disorder, some with chronic disorders.

As the above quote from SAMSHA’s Overview Paper #3: Overarching Principals to Address the Needs of Persons with Co-occurring Disorders affirms, over 20 years of research has settled the old question of which of these disorders should be treated as primary by demonstrating that integrated treatment, which treats both disorders concurrently, offers the best possible outcomes for clients and client’s families. The Co-occurring Disorders Program, to be published by Hazelden in September 2008, offers a comprehensive, manualized system that supports evidence-based, integrated treatment for these disorders.

The Dartmouth Psychiatric Research Center developed and tested the Integrated Dual Disorder Treatment (IDDT) model, which is now an established evidence-based practice designed for people with severe mental illness (SMI). Drawing upon the numerous randomized controlled trials testing the IDDT model, as well as the rapidly accumulating evidence for practices with co-occurring substance use and non-SMI disorders, the Co-occurring Disorders Program represents the state-of-the-science in treatment approaches for people in addiction treatment settings. Since the evidence base for co-occurring disorders in addiction treatment exists on a continuum, each component of this Program will describe the scientific status of the various treatment approaches, from investigative to promising to established practices. In some components, careful adaptations of evidence-based approaches, for example the family education approach, are made in order to be relevant for the non-SMI client in an addiction treatment program.

The therapeutic interventions documented in this Program are primarily drawn from current best practices in cognitive-behavioral therapy, motivational interviewing, and Twelve Step facilitation. These materials have been developed within the context of addiction treatment programs treating clients either individually or in groups, but are equally useful when applied in a mental health program that would like to offer integrated treatment for co-occurring disorders. The package includes all the support tools necessary to implement an integrated treatment program to fulfill the needs of administrators, clinicians, patients, family members, team members, and other stakeholders.

The seven components of the Co-occurring Disorders Program are designed for use with adult patients, as well as their family members, who are participating in a residential or outpatient treatment and/or mental health program for substance use and non-severe mental health disorders. The program components listed below, include a manual, five 3-ring binder curricula with CD-ROMs, and a DVD.

Program Manual: Clinical Administrator’s Guidebook

This perfect-bound manual contains complete instructions for implementing the Co-occurring Disorders Program. The guidebook is for a mental health or addiction treatment organization’s director, board of directors, CEO, CFO, and other key agency leaders. This guidebook offers all the tools a clinical administrator needs to assess the seven key areas of organizational effectiveness, including the policy, practice, and workforce benchmarks needed to deliver the best possible services to persons with co-occurring disorders. The Clinical Administrator’s Guidebook also contains a valuable organizational assessment guide, which outlines the steps needed to assess and improve services offered to patients with co-occurring disorders. Links to resources about co-occurring disorders, a sample charter agreement and DDCAT implementation plan, and other materials are included on the accompanying CD-ROM.

Curriculum One: Screening and Assessment

The first of the five curriculum components is a must-use tool that helps clinicians evaluate patients with an effective, protocol-driven method so that appropriate treatment options can be addressed with regard to each patient’s symptoms, history, and motivation to change. Included are specific measures for screening, assessment, differential diagnostics, and stage of motivation to address and treat both addiction and psychiatric problems in patients. Screening and Assessment comes with a bound clinician’s guide and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Two: Cognitive-Behavioral Therapy

The second curriculum utilizes cognitive-behavioral therapy (CBT) principles to address the most common psychiatric problems in addiction settings: depression, anxiety disorders, bipolar disorder, social phobia, and post-traumatic stress disorder (PTSD). Adaptations of CBT are an evidence-based practice for treating substance use disorders and most psychiatric disorders. Research shows that CBT is useful for treating non-severe co-occurring psychiatric disorders in an addiction treatment setting. Psychosocial treatments, particularly CBT, are equally, if not more, effective for the psychiatric disorders that most commonly occur with substance use disorders. Research with CBT for persons with co-occurring disorders has been highly specialized by the specific co-occurring disorder. Until now, providers had no one manual or practice to implement in real-world settings where patients have a variety of these disorders. Cognitive-Behavioral Therapy includes a bound clinician’s guide and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Three: Integrating Combined Therapies

The third curriculum utilizes a combination of motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and Twelve Step facilitation (TSF) therapy. Each of these models of therapy has been proven successful when used in community addiction treatment programs. There is a growing consensus that these practices are effective if delivered singularly to patients, but are even more effective if rationally combined based on stage of motivation, problem pattern and severity, and patient preference. We can think of MET as serving the role to engage change, CBT working to assist change, and TSF as a proven model to sustain change and elaborate upon it. Each of these evidence-based practices is described here with appropriate modifications for persons with co-occurring disorders. This curriculum will enable a clinician to successfully deliver these evidence-based substance dependence treatment therapies to patients with co-occurring disorders, resulting in greater positive outcomes for clients. Integrating Combined Therapies comes with a bound clinician’s guide and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Four: Medication Management

The fourth curriculum is a valuable resource for medical directors and clinicians. It contains vital, current information about the complex issues of medication management, including medication compliance and other psychological concerns of the patient. Issues of differential diagnosis, timing, indications, monitoring, dosage, tolerance and withdrawal, and other topics are considered in this component. Current evidence and consensus-based practices are provided to enable providers to make clinical decisions about medications and their prescription. While many people in peer support groups take psychotropic medication, stigma can still cause some to hide their medication use from others. These issues, and information about the benefits and risks of medications, are also addressed for the patient. Medication Management comes with clinician’s instructions and a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Curriculum Five: Family Program

The fifth curriculum helps clinicians involve patients with co-occurring disorders and their family members in an integrated treatment approach.First, family members, including the patient,meet to learn about the patient's specific psychiatric disorder andhowit interacts withthe substance use disorder. Then, the family joins other families in a 12-week program of education on such topics as managing cravings, effective communication, using medications, and preventing relapses. The Family Program component includes a bound clinician’smanualand a CD-ROM with reproducible patient handouts packaged in a three-ring binder.

Program Video: Hope and Healing for Co-occurring Disorder Patients and their Families

This 90-minute DVD educates patients and families on the treatment of co-occurring disorders. It provides an educational overview of co-occurring disorders, offers interviews from people who have them, and discusses ways that patients can participate in treatment to better manage their recovery from both disorders. Included are dramatic vignettes as well as professional narration to show a comprehensive look at all the issues of recovery. Clinicians can use this DVD when implementing all seven components of the Co-occurring Disorders Program or as a stand-alone with the Family Program.

Implementation training developed by Hazelden and the faculty of Dartmouth Psychiatric Research Center to help treatment and mental health centers develop greater capacity, skills, and processes to treat non-severe mental health patients with substance use disorders will be available when the Program is released in September 2008.

Pricing and ordering information for Co-occurring Disorders Program and the implementation training will be announced in April 2008.

About the Authors

Mark McGovern is an associate professor of Psychiatry and of Community and Family Medicine at Dartmouth Medical School. Dr. McGovern specializes in the treatment of co-occurring substance use and psychiatric disorders and practices through the Department of Psychiatry at Dartmouth-Hitchcock Medical Center. In July of 2004, he received a five-year career development award from the National Institute on Drug Abuse. The overarching goal of this award involves developing, testing, and transferring evidence-based treatments to community settings for persons with co-occurring substance use and psychiatric disorders.

Robert E. Drake, M.D., Ph.D., is the Andrew Thomson Professor of Psychiatry and of Community and Family Medicine at Dartmouth Medical School and the director of the Dartmouth Psychiatric Research Center and is currently vice chair and director of research in the department of Psychiatry. He works as a community mental health doctor and researcher. His research focuses on co-occurring disorders, vocational rehabilitation, health services research, and evidence-based practices. He directs four national studies of quality improvement, and he has written fifteen books and over 360 papers.

Matthew Merrens, Ph.D.,< is codirector of Dartmouth Evidence-Based Practices Center and visiting professor of Psychiatry at Dartmouth Medical School. He received his Ph.D. in clinical psychology at the University of Montana and was formerly on the faculty and chair of the Psychology Department at the State University of New York–Plattsburgh. He has extensive experience in clinical psychology and community mental health and has authored and edited textbooks in the psychology of personality, introductory psychology, the psychology of development, and social psychology. He recently published a book on evidence-based mental health practice.

Kim T. Mueser, Ph.D., is a licensed clinical psychologist and a professor in the Department of Psychiatry and the Department of Community and Family Medicine at the Dartmouth Medical School . Dr. Mueser’s clinical and research interests include integrated treatment for co-occurring psychiatric and substance use disorders, rehabilitation for persons with severe mental illnesses, and the treatment of post-traumatic stress disorder. He has published several hundred journal articles and has coauthored or edited ten books.

Mary F. Brunette, M.D., is an associate professor of Psychiatry at Dartmouth Medical School. She conducts research on services and medications for people with co-occurring substance abuse and serious mental illness at Dartmouth Medical School. She also is medical director of the Bureau of Behavioral Health in the New Hampshire Department of Health and Human Services. She has published over thirty articles in peer-reviewed journals, many related to medication treatment for people with co-occurring disorders. She speaks nationally on this topic.

Richard Hendrick, who produced the DVD, is a television writer, producer, and director and an educator. He has created award-winning productions for PBS, Turner Broadcasting, and A&E, among others. He taught for many years at Dartmouth College, including courses in developmental psychology, educational technology, and television and children, and has also lectured at Harvard Graduate School of Education, Columbia University, Bank Street College, and the University of Siena in Italy.

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50 Years of Mental Health Hope and Struggle: 1957-2007

Council on Crime and Justice’s 50th Anniversary Forum
October 10, 2007, Minneapolis Convention Center
By: Mark Anderson and Lynda Cannova

Mark Anderson, founding Executive Director of the Barbara Schneider Foundation, was Senior Policy Advisor on mental health and related issues for Wellstone’s 12 years in the U.S. Senatae. 1989-1990, Director of Board and Commission Appointments in the Office of Governor Rudy Perpich. He has an MA, in Liberal Studies, HamlineUniversity. Lynda Cannova is the mother of two grown sons with schizophrenia. She has worked with Barbara Schneider Foundation on policy development and outreach for three years. She has an MSW from the University of Minnesota School of Social Work.

In the last 50 years there have been dramatic changes in systems of care for those with mental illness, and in how this care is financed. There have been exciting advances in the science of the brain that helps us understand what mental illness really is and how we can respond to it. But even with all the improvements in what we know and what we do, the lives of those with a mental illness have not improved nearly as much as they could have. We know much more now than we did fifty years ago, but our society’s institutions have not kept up so we continue to fall short. Where our health care systems have failed, our criminal justice system has taken on the burden with problematic consequences.

According to the Surgeon General's Report on Mental Illness, it is estimated that in an average one-year period, 22 to 23 percent of the U.S. adult population—or 44 million people—have diagnosable mental disorders. About 28 to 30 percent of the population has either a mental or addictive disorder. It is estimated that 9 percent of all U.S. adults have mental disorders experience some significant functional impairment. Five percent of adults are considered to have a “serious” mental illness. About half of those (or 2.6 percent of all adults) were identified as being even more seriously affected, that is, by having “severe and persistent” mental illness. This category includes schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder. Today, only 60% of severely mentally ill persons receive treatment in a given year, leaving approximately 2.2 million severely mentally ill persons untreated (Torrey, 1997).

In 1957 mental health treatment was typically provided in large state hospitals and other institutions. This was the era when pharmaceutical treatment of mental illness was just beginning and an affordable community based mental health system did not exist. Patients were sent to these institutions for care and often spent many years there. Families could care for their family members in their own home, as had been done since time immemorial but, in an increasingly urbanized society, that style of care was less possible for many. These state run institutions were seen as humane alternatives to incarceration or homelessness.

According to the groundbreaking first Surgeon General’s Report on Mental Health, “In the 1950s, the public viewed mental illness as a stigmatized condition and displayed an unscientific understanding of mental illness. Survey respondents typically were not able to identify individuals as “mentally ill” when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of behavior—namely psychosis—as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior.”

With the invention of new pharmaceuticals, that made it possible to moderate the extreme behavior of many who lived in these institutions, it was thought that allowing patients to leave and be treated in the community would be more humane.

President John Kennedy supported the Community Mental Health Act of 1963 which provided federal financing to states to develop community mental health centers. These community mental health centers developed as an important part of our mental health system, and formed an important core of a growing community mental health movement. But they were never adequately funded and so were never able to provide community based mental health care for all those who had been deinstitutionalized. Deinstitutionalization reduced the population of state and county mental hospitals from a high of about 560,000 in 1955 to well below 100,000 by the 1990s. De-institutionalization has eliminated over 90% of former state psychiatric hospital beds (Sigurdson, 2000). But an adequate community based mental health system has even today not been created.

On July 30, 1965 Medicare, a federal single payer system for those over 65 and, after 1972 for those with a disability, was created. Its companion program Medicaid was also created to cover long term care for the elderly and others and care for mothers and children who met income guidelines. Unfortunately Medicare, to this day, discriminates against mental health coverage, charging a 50% co-pay for mental health care and a 20% co-pay for medical and surgical care. In addition, there was no Medicare coverage for pharmaceutical care outside the hospital setting for the first 4 decades of the program. And Medicaid is moving to a managed care model that has not worked well with this population.

The development of a wide variety of pharmaceuticals lead to an increased reliance on pharmaceutical care rather than hospital care for mental health as well as medical and surgical care. After the failed 1992 national health care reform effort, managed care became the standard way to organize care including mental health care. This business model of mental health treatment helped further medicalize mental health care by disconnecting it from support services. The rise in reliance on pharmaceutical care, combined with managed care led to a decrease in talk therapy and a failure to provide needed support services to those who were de-institutionalized. In fact it would not be an understatement to say that pharmaceutical companies took on a growing role in defining care options. In mental health this lead to the colloquialism, “off his meds,” to refer to someone who was exhibiting symptoms of psychiatric illness.

In speeches to medical societies in the 1940s and 1950s, Bill W., the founder of Alcoholics Anonymous, noted the important role played by leading psychiatrists in the development of AA. And yet there developed a split between the treatment of mental illness and the treatment of substance abuse and addiction. The varying stigma associated with these two sets of disorders and the public’s and the health care community’s failure to understand their inter-relationship lead to a situation where patients with co-occuring mental illness and substance abuse or addiction we bounced back and forth between these systems because neither system was fully able to treat both disorders. This is now changing due to the new brain science that is clarifying the underlying disease processes at work and making possible the identification of effective dual-diagnosis treatments.

After the Vietnam War, military veterans fought for years to gain the recognition of the diagnosis of post traumatic stress disorder, PTSD, as a diagnosable and treatable mental health disorder. Later it was recognized that other sufferers of trauma, sexual assault, torture, children who witness violence, and others, could also be affected by PTSD. During the current conflicts in Iraq and Afghanistan, it is being recognized that combat and operational stress are treatable disorders and that their immediate treatment can lower rates of PTSD in warriors who experience the stress of life in the combat zone. In addition, military health care providers are seeing the importance of traumatic brain injury, TBI, and this is leading to the recognition of the importance of treatment of this disorder throughout the health care system.

Consumer movements like those that lead to the recognition of PTSD have also grown up with a number of other mental health disorders. Consumer organizations, and organizations of family members of those with mental illness, have played an important role in recent years in raising awareness among policy maker and health care leaders in the need to treat mental illness.

Beginning in the 1960s, the feminist movement helped re-define women’s mental health.

Communities of color pressed for respect for cultural differences in mental health care and began to insist on cultural competence by mental health providers so that providers would have the ability to develop rapport and a healing relationship with their patients and clients.

As society changed its view of mental illness, the courts became more understanding of mental health related issues. Civil commitment proceedings were reformed and criminal mental health courts created.

There was a growing understanding of the relationship between children’s and adult mental health. School districts have become much more aware of the barriers to success in education that mental illnesses create for children. And yet schools are not health care institutions and their failure to adequately respond to the needs of children with a mental illness has contributed to the overwhelming majority of children in our juvenile justice system having a diagnosed mental health disorder.

The American’s with Disabilities Act, ADA, which took effect on July 26, 1992, supported parents and consumers’ insistence on an appropriate response to mental illness in the workplace and public accommodations.

Particularly since 1990, advances in brain science, brain scans, growing understanding in brain biochemistry, advances in psychological therapy, electrical brain stimulation, and the role of the genome in brain development and functioning are bringing important new understandings to health care providers, policy makers and the public.

There is an increased understanding that the mind/body split that 18th century philosophers detailed is a fiction. The brain is a real part of the body and the brain and other organs of the body interact in numerous ways so that a health care system that does not treat the brain with the body is outmoded. This new understanding is reflected in the Mental Health Parity Act of 1996 which broke down some of the discrimination against mental health care. So called full parity between mental health, substance abuse treatment and medical and surgical treatment has been under consideration by congress since the mid 1990s and appears closer than ever to passage this year. And at the state level, 1997 saw passage of uniform mental health benefits in all the major public health care program benefit sets. Mental health parity has already been the law in Minnesota since the 1990s.

Today there is an overwhelming need to update all health care, public safety, criminal justice and social service institutions to utilize the new insights that science provides. These systems, which in many cases are based on models that are centuries old, must be updated based on this new knowledge.

In spite of all the progress made in the mental health system in the last 50 years, our current mental health system reflects a social and political mental health injustice. Mental health care providers report that our capacity for emergency psychiatric care is regressing to a time 40 years ago when providers had to accompany patients to the emergency room and wait with them for care. Criminal justice professionals report that 60-75% of those in some of our jails have a mental illness. There are more persons with mental illness in jails and prisons than in all state hospitals combined. Many have identified this situation as the criminalization of the mentally ill.

Due to the decreasing number of inpatient beds and the lack of needed community based mental health providers, many people struggling with severe mental illness find themselves repeatedly and unnecessarily in mental health crisis. Many of them will end up committing suicide, as crime victims, and encountering the police. Clearly reform is needed. There is a need for comprehensive and effective long-term care environment for this high risk population. People with severe mental illness are frequently turned away from treatment facilities and often wind up in jail or are homeless due to lack of treatment. These individuals often have to go through the criminal justice system to get the treatment they need.

In the current situation a large percentage, estimated at 30%, of the population in the criminal justice system is on psychotropic medications to treat severe mental illness; the historic and continuing decline in inpatient beds in mental health hospitals and hospital psychiatric wards; the lack of community based programs to provide long term support to people with severe mental illness needed to avoid repeated hospitalizations, homelessness, suicide, and the number of people who die each year because of the inadequacy of our prevention systems make this proposal profoundly important. Besides these disastrous results our current view of mental health as a social welfare and public safety issue promotes actual loss of liberty when someone who is mentally ill but untreated commits a crime and ends up incarcerated, often being forced into treatment that could easily have been given on a preventive basis in the community.

Research has proven that mental illness is a biological brain disease and not a lifestyle choice. When someone is sick, whether from disease that can be seen under a microscope or from one that strikes the mind invisibly, treatment is required. Unfortunately the current system for providing treatment for those with psychiatric disorders remains dangerously troubled. There is inequity in laws concerning the mentally ill in that they are not guaranteed the right to high quality treatment given to people with other organic but not behavioral illnesses. To be equitable, the mentally ill should have the same right to get treatment as people with any other debilitating disease or disorder. If mental illnesses are not understood as medical conditions, then equity is not a feature of laws and services. People with severe heart conditions or diabetes and cancer can access treatment by going to a doctor’s office or hospital, while the mentally ill are often turned away from treatment facilities. Appropriate response to this population can help save lives, save law enforcement, court, incarceration and health care costs, reduce homelessness, and improve the lives of people with severe mental illness and the lives of their loved ones.

Since the 1970s police departments across the country have seen a sharp increase in calls involving persons with mental illness (Torrey, 1997). It is estimated that between 7-10% of law enforcement contacts involve persons with mental illness (Bailey 2001, Hails & Borum, 2003). Research also indicates that in police encounters, persons with mental illness are more likely to be arrested than those who are not (Teplin, 2000). This high rate of law enforcement contact with persons with mental illness has led to incidents that have resulted in injury or death for the mentally ill. For example in Los Angeles, over a six-year period confrontations with the mentally ill ended in 25 fatal shootings by police (Bailey 2001). One study in a large law enforcement agency found that “suicide by cop” accounted for 11% of all officer-involved shootings (Lamb, Weinberger, DeCuir, 2002).

Recent strides by science in the understanding brain and biological factors that contribute to mental illnesses make these illnesses diagnosable and successfully treatable. This progress has not been matched by public policy in guiding our response to mental illness. Law enforcement response to mental health crisis involves a great deal of discretion in determining the outcome. Police decisions at a scene often determine whether a person will enter the mental health or the criminal justice system; yet officers often have very little training in identifying and working with persons exhibiting mental illness.

Police officers are called on to respond to mental health crisis situations while ensuring officer safety, public safety and on scene resolution or transport to the mental health system. Police need specialized response programs to respond appropriately and effectively.

Persons with mental illness face many risk factors which impact their chances of encounters with law enforcement and for incarceration, including dual-diagnosis with chemical dependency, homelessness, and treatment non-compliance (Munetz, Grande & Chambers, 2001). It is estimated that between 20-30% of the adult homeless population suffers from a severe mental illness (Sigurdson, 2000). In addition 80-90% of mentally ill offenders are estimated to have co-occuring substance abuse problems (Sigurdson, 2000). Disordered thinking and paranoid delusions can lead to nuisances as perceived by the public and even criminal, sometimes dangerous, behavior.

Along with the reports of increased police involvement, reports of large numbers of mentally ill persons in U.S. jails and prisons began appearing in the 1970s (Lamb & Weinberg 1998, Torrey, 1997). Approximately 685,000 persons with severe mental illness are admitted to U.S. jails every year and between 6-15% of jail inmates have a severe mental illness (Hails & Borum, 2003; Lamb & Weinberg, 1998). The U.S. Department of Justice estimates that in 1998 there were 283,800 mentally ill offenders in U.S. prisons and jails, representing 16% of state prison inmates, 7% of federal inmates, and 16% of those in local jails (Ditton, 1999). The incarceration of persons with mental illness has become so rampant that professionals in the field claim that jails and prisons have become mental health facilities (Faust 2003, Howd 1998, Torrey 1997). This has major implications for criminal justice funding, for the cost of imprisonment often exceeds the cost of appropriate mental health care in the community (Sigurdson 2000). Mentally ill offenders are considered to have the highest rate of recidivism of any group of offenders (Sigurdson 2000).

Law enforcement has a professional responsibility to respond to persons with mental illness who are experiencing crises. There are two common law principles that create the opportunity for police officers to become involved with persons with mental illness. The first is that the police have the authority and responsibility to ensure public safety. Secondly, officers have a parens patriae obligation to protect persons with disabilities who cannot care for themselves (Lamb et al., 2002). Police have the authority to initiate a psychiatric emergency apprehension when a person poses a danger to themselves or others or if unable to provide for his or her own basic physical needs necessary to protect oneself from harm (Teplin, 2000). Police officers are often the first responders to people in crisis, but often lack the training necessary to respond appropriately (Patch & Arrigo, 1999).

Police officers typically have three options when encountering a person with mental illness who is creating a disturbance or is in crisis: 1) resolve the situation informally at the scene; 2) transport the person to a mental hospital; or 3) arrest the person (Teplin, 2000). Law enforcement response to persons who are apparently mentally ill involves a lot of discretion in determining the outcome (Patch & Arrigo, 1999). The decisions that police make at a scene involving a person exhibiting mental illness often determine whether a person will enter the mental health system or the criminal justice system. Depending on other community resources, police officers are often the only responders to situations involving persons with mental illness who are experiencing crisis. This is why police officers are often referred to as “street-corner psychiatrists” (Teplin, 2000) or gatekeepers (Patch & Arrigo, 1999).

This role that police officers take on as “street-corner psychiatrists” can be problematic because they often have very little training in identifying and working with persons exhibiting mental illness. Sometimes police do not have the training necessary to distinguish between whether someone’s behavior is a manifestation of mental illness or it is unlawful behavior (Hails & Borum, 2003). When asked, police officers will often identify that they feel unprepared to respond to such situations (Hails & Borum, 2003) and identify that they would like to receive training in how to recognize mental illness, how to respond to situations, and what community resources are available for persons with mental illness (Lamb et al., 2002). Also, research indicates that police interactions with persons exhibiting mental illness are different from interactions with persons who are not apparently mentally ill. Teplin conducted a study in 1980 in which it was found that persons with mental illness have a 67% greater chance to be arrested than those who apparently were not mentally ill (2000).

There is also a concern regarding the use of excessive force with persons with mental illness. As discussed above, interactions between police and persons with mental illness have unfortunately led to death and injury for both persons with mental illness and involved police officers. Although more research is needed, national data indicates that force is more likely to be used with persons with mental illness. Police training in the use of interpersonal skills for de-escalation, the use of less lethal weapons, such as tasers, and other tactics are all issues that impact the use of force by police officers.

When police officers do try to initiate a psychiatric response, by transporting a person for emergency apprehension, they often face barriers. Due to the cuts in funding experienced by the mental health system, many hospitals have a limited number of psychiatric beds. Some programs also have regulations on whom they will accept, such as not accepting persons who are considered dangerous or if they have a co-occurring substance abuse problem (Teplin, 2000). Sometimes officers will transport a person for hospitalization or psychiatric evaluation, just to have the person back on the streets with in hours--creating a revolving door for criminal justice response. In addition, when officers transport a person to the hospital, they sometimes will face a long wait to transfer the individual, which takes the officer away from their patrol duties. In addition, psychiatric care may be more available in the jails than in the community system. Given the barriers officers often face when trying to initiate a psychiatric hospitalization, sometimes arrest is viewed as a simpler and more reliable way to resolve some situations (Teplin, 2000). This is often referred to as “mercy bookings” and is used both when officers do not feel like they have any other realistic choice and also when they believe that it is in the person‘s best interest, for they will receive shelter and possibly mental health services provided by the system (Sigurdson, 2000; Torrey, 1997).

There is growing evidence that formal collaboration between law enforcement and the mental health system is critical for the best law enforcement response to persons with mental illness (Klein, 2002; Gentz & Goree 2003; Lamb et al 2002; Sigurdson 2000; Steadman, 2000 & 2001; Teplin, 2000; Thompson 2003). Police-based diversion programs, involving collaboration with the mental health system have emerged. As compared to court-based diversion, police-based diversion happens before booking and the filing of charges and involves police making direct referrals to community-based mental health or substance abuse programs as an alternative to arrest and detention (Steadman, et. al. 2000). Diversion programs have been shown to work in both decreasing subsequent hospitalizations and recidivism (Sigurdson, 2000).

The Barbara Schneider Foundation was born out of a tragedy that occurred on June 12, 2000. Local police, called in on a noise complaint, shot Barbara Schneider to death in her own home. Six police officers entered her Minneapolis apartment when she was having a mental health crisis. The police were untrained to deal with this call as a health care intervention and rather than de-escalating the crisis they confronted her with force. She had a deadly weapon and she did not back down, as is not uncommon with individuals in mental health crisis.

The mental health community responded by building a long term dialogue with law enforcement and they partnered to prevent such tragedies from re-occurring. In fact the crisis of Barbara Schneider’s death has lead to training in for those responding to individuals in crisis for police, jailers, paramedics, nurses, mental health professionals and social service providers by Barbara Schneider Foundation and their partners in the community. There is a growing awareness of the need to improve our response to mental illness and to build collaborations across all the institutions that respond to those at risk for mental health crisis. This growing consumer lead movement is challenging all the systems in health care and criminal justice to make urgently needed changes. It is this growing voice of those who themselves struggle with a mental illness that provides hope that fairness for those with mental illness can prevail over the forces of ignorance, denial, discrimination, greed and stigma.

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From Minnesota Health Care News, February 2007

Mental Health Crisis Intervention:
A prepared response can avert a tragedy

By Mark Anderson

The human brain is a wonder to behold. It brings us consciousness and insight, it invents science and philosophy, and creates the performance of the Olympic athlete and the jazz musician. But like any other organ of the body, it can suffer from illnesses and injuries. When the brain gets in trouble we see the symptoms of mental illness. And when the individual struggling with these symptoms becomes overwhelmed, a mental health crisis can occur.

When people in your family or community experience a mental health crisis, they might be reacting to any number of physical and mental conditions. They might hear voices as if listening to a non-existent radio or as if there is another person inside their head. They might see beings or other objects that are not real, or experience changes in perception, (e.g., of colors). They might be having profound delusions such as believing that threatening figures are plotting against them. They might be struggling with severe depression and contemplating suicide. They might be experiencing the high energy, erratic behavior and sleeplessness of mania. Or they might not realize they have memory loss and impulsivity caused by physical or chemical brain trauma.

A mental health crisis can be any one of the scenarios in this broad spectrum because many parts of the brain can be in crisis. And of course these and other symptoms can occur in combination. So there are many behaviors that we might observe in an event known as mental health crisis. Those who are not mental health professionals need not diagnose the illness. Even highly-trained scientists and clinicians struggle to find an accurate diagnosis in many cases.

But we can all help people in crisis by helping them get to the professional help they need. That means helping them find safe transportation to a crisis center equipped to respond to psychiatric illness. In many cases this help can bring the individual back to mental health so they can resume their life, or even find a more fulfilling life.

A crisis in your home or community

If someone exhibits symptoms of a mental health crisis, you should proceed with caution and restraint. In most cases, a person in crisis is very vulnerable and is not a threat to public safety. You may be able to transport the person to the nearest hospital. If you do, be prepared for a long wait, up to eight hours or longer are common. Having you there will help the health care professionals understand the nature of the crisis that brought you to their facility, and you can serve as a valuable advocate for the person in crisis. Don't be afraid to speak up strongly on behalf of the person you brought in.

In some cases, it is best to seek immediate help. If a weapon is involved or there apprears to be a danger to public safety, then it is appropriate to call 911. The 911 caller should describe the behavior that is observed at the scene and ask the 911 operator to dispatch a mental health crisis responder. It is important to describe the specific behavior because the dispatcher makes an independent assessment whether this is a mental health crisis call. And the more specific the information is, the more likely the responders will be prepared when they arrive at the scene. More and more police departments have CIT (Crisis Intervention Team) officers, specifically trained to respond to mental health crisis calls. And many counties in Minnesota now have Mobile Crisis Teams of mental health professionals. It is likely that the mobile crisis team will have its own phone number independent of the 911 system.

While the responder is on the way to the crisis it is important to make efforts to de-escalate the crisis, if this can be done safely. Express your support and concern to the person in crisis. Listen to his story. Give him space so he doesn't feel trapped and try to reduce stimulation by limiting the number of people and other distractions. Speak slowly and softly, and avoid touching, shouting or continuous eye contact. When the responders arrive, offer your assistance but let them do what they are trained to do and don't interfere.

Developing an emergency plan

Before any crisis occurs it is helpful for family members to have developed a plan for handling such an event, similar to handling any health care emergency, but with a focus on the unique aspects of a mental health crisis. Many crises can not be anticipated. But you foresee the possibility of such an occurance with a family member or close friend, you should be prepared. You should create a packet for yourself that includes contact information for a physician and or therapist who knows the person's health history, the county mobile crisis team, the local police, or other first responders in your community. Mental health responders often have their own phone numbers and sometimes won't be dispatched through the 911 system.

Each community has a different array of resources to respond to mental illness. Having a conversation with a community mental health center or an emergency psychiatric facility where first responders take those in crisis is an important part of developing a strategy for responding to a mental health crisis.

Prevention: the best outcome

Prevention of the crisis in the first place is the best outcome. Each additional crisis event a person experiences can cause further damage to the brain. And a crisis and the response to the crisis can be unpredictable, and can unfortunately sometimes even lead to injury or death. We all need to plan ahead and know what resources are available in our own local community, so we are prepared in case we need to respond to a mental health crisis.

Prevention also means that we all need to combat stigma and discrimination that people with mental illness face. Individuals that are struggling with mental health problems should be encouraged and supported to seek health care. Community education can help combat stigma so that anyone struggling with mental illness can receive support from others in the community. Part of this process of being prepared is having improved understanding of cultural sensitivities and attitudes to mental illness. Different cultures understand mental illness and mental health care in different ways and knowledge of these differences can often improve the quality of a crisis response.

A tragic case

Even though it occurred over six years ago, the death of Barbara Schneider on June 12, 2000, is still remembered by many in Minnesota. She was shot in her Uptown, Minneapolis home by police during a confrontation in a mental health crisis call. Since that incident, mental health advocates have worked with their partners in criminal justice, and emergency medicine to improve the response to crisis events and to work toward de-criminalization of mental illness. Only a strong partnership between the mental health, criminal justice, and emergency medicine communities can improve crisis response to those who need this help.

Another vital part of improving crisis response is public education about the nature of mental illness, removing the social stigma of mental illness, and improving the resources available to help those who need care. Getting this message out to the public and to policymakers will result in more appropriate and effective mental health crisis response, improved first responder safety, and growing collaboration among everyone involved.

Such collaboration can prevent tragic events like Barbara Schneider's death and ensure that our families and communities are safer and healthier places to live and work.

Mark Anderson is Executive Director of the Barbara Schneider Foundation, and leads their efforts to build mental health/criminal justice collaborations in training, education and advocacy.

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Abstract

Introduction

Methods

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Discussion

Conclusions

Acknowledgments

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References

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Council on Crime and Justice’s 50th Anniversary Forum October 10, 2007, Minneapolis Convention Center By: Mark Anderson and Lynda Cannova

Mental Health Crisis Intervention: A prepared response can avert a tragedy

By Mark Anderson

A crisis in your home or community

Developing an emergency plan

Prevention: the best outcome

A tragic case

Making the case for treatment:
Details on the interface between a local care system and the criminal justice system

Combination of factors drive up danger, researchers say

By Carla K. Johnson, Associated Press
In the Pioneer Press, St Paul Minnesota

In dealing with the mentally ill
in jail, officials try a new way

When a desperate teen in Shoreview
met a good cop who wouldn't give up

NAMI's Public Policy Position on
Tasers and Related Weapons

8.9 Application of Less Lethal Weapons
by Law Enforcement Officers

Crisis Intervention Team Training
for Police Officers Responding to Mental Disturbance Calls

Council on Crime and Justice’s 50th Anniversary Forum
October 10, 2007, Minneapolis Convention Center
By: Mark Anderson and Lynda Cannova

Mental Health Crisis Intervention:
A prepared response can avert a tragedy