Literature Reivew

https://doi.org/10.1080/15614263.2018.1484290

Crisis intervention team training: when police encounter persons with mental illness

Michele P. Bratinaa, Kelly M. Carrerob, Bitna Kimc and Alida V. Merloc

adepartment of criminal Justice, West chester University of Pennsylvania, West chester, Pa, Usa; bdepartment of Psychology, counseling, & special education, texas a & M University–commerce, commerce, tX, Usa; cdepartment of criminology & criminal Justice, indiana University of Pennsylvania, indiana, Pa, Usa

ABSTRACT The Crisis Intervention Team (CIT) model is an established training program used to improve police response to encounters involving persons with mental illness (PwMI). Diversion of PwMI from the criminal justice system to appropriate treatment providers in the community is one of the primary goals of CIT. The present study examines characteristics and outcomes of encounters between citizens experiencing mental health-related crises and CIT-trained patrol officers. Findings of this study indicate encounters involving PwMI and CIT-trained officers often result in diversion to mental health services. Implications for policy and future research are discussed.

In conjunction with policing in general, recent police encounters with citizens in crisis have garnered the attention of criminal justice and mental health practitioners, criminologists, and the media. As a response to interactions involving persons with mental illness (PwMI) and the criminal justice system local jurisdictions in the United States and abroad have implemented specialized training programs to deescalate crisis and divert PwMI to treatment services (Slate, Buffington-Vollum, & Johnson, 2013). The Crisis Intervention Team (CIT) model is the most popular training program to improve police response in this context (Hartford, Carey, & Mendonca, 2006).

The fields of psychiatry, behavioral science, psychology, public health, and social work have also made or are making contributions to research on CIT (e.g., Borum, Deane, Steadman, & Morrissey, 1998; Franz & Borum, 2010; Compton, Esterberg, McGee, Kotwicki, & Oliva, 2006; Compton et al., 2011; DeMatteo, LaDuke, Locklair, & Heilbrun, 2013; Ogloff et al., 2013). The evidence is cautiously positive with respect to the success of CIT programs in diversion efforts and in maintaining the safety of officers and consumers. The Memphis model1 is the most popular in terms of large-scale implementation; yet empirical research on its effectiveness has been limited (Broussard et al., 2011).

Rigorous research investigating the effectiveness of CIT is scant but developing (Taheri, 2016). Unfortunately, little is known about specific police contact rates and processes involved in critical police encounters with PwMI. Franz and Borum’s (2010) study is the exception. Using a sample of CIT calls in Central Florida from 2001 to 2005, they found that CIT training prevents arrests and decreases arrest rates of PwMI. Specifically, each year after the implementation of CIT, arrests for mental health disturbance calls steadily decreased over a five-year period.

The present study explores encounters between officers trained in the Memphis Model and PwMI in one South Florida region. Self-reported police data from documented crisis calls in a medium-sized

© 2018 informa UK limited, trading as taylor & Francis Group

KEYWORDS crisis intervention team; mental health; policing

ARTICLE HISTORY received 5 september 2017 accepted 26 May 2018

CONTACT Michele P. Bratina mbratina@wcupa.edu

POLICE PRACTICE AND RESEARCH 2020, VOL. 21, NO. 3, 279–296

jurisdiction were analyzed using bivariate analysis. The ultimate goal is the dissemination of informa- tion that potentially supports the continued development, implementation, and expansion of training to improve police encounters with citizens (many of whom have been identified as PwMI). This study updates and expands on similar diversion work in central Florida (see Franz & Borum, 2010); and it is intended to contribute to the policy debate.

Statement of the problem

Current statistics on mental illness prevalence reveal that one in every four adults in any given year, or about 61.5 million Americans, will experience a diagnosable mental illness at some point in his/her lifetime (National Alliance on Mental Illness, 2013a). Although it has been reported that about 3–6% of police encounters involve PwMI (Schwarzfeld, Reuland, & Plotkin, 2008), statistics also indicate that a disproportionate number of PwMI are involved in critical police encounters resulting in arrest, and at the most extreme end of the spectrum, police shootings (Franz & Borum, 2010; Ogloff et al., 2013). For example, in 2016 the Washington Post reported that police killed 963 people, and 241 of them (i.e., 25%) were linked to mental illness. Similarly, Morabito and Socia (2015) examined all use of force cases reported by city police departments between 2008 and 2011 in Portland, Oregon, and found a significant relationship between subjects’ mental health and likelihood of injury to either subjects or the police officers when force was employed – but only when citizens also had substance abuse issues present at the time of the encounter.

Despite the increase in police encounters with persons in crisis, it appears that minimal attention in police training deals with individuals who might be experiencing mental health issues. Most training academies allot approximately 60 h on how to use a gun, but only 8 h for strategies to address persons with mental illness (Lowery et al., 2015). It is important to recognize the cross-systems nature of PwMI, and gaps in available mental health-related training for police and other first responders, are only part of the problem in responding to and managing this population.

Recently, the intersection between the mental health and criminal justice systems has been empha- sized as evidenced by media reports of police brutality toward PwMI (e.g., Borrelli, 2015 & McLaughlin, 2015) and mistreatment of inmates with mental illness by correctional staff and contracted mental health providers in jails and prisons (e.g., Berman, 2015; Fellner, 2015; Miller, 2015). Simultaneously, the limited literature on effective responses to justice-involved offenders with severe and persistent mental illness also has been documented. Further research is particularly necessary in policing and corrections – the components of the system facing challenges in terms of responding effectively in situations involving PwMI in their care (Cross et al., 2014; DeMatteo et al., 2013; Lucas, 2016).

Police as primary gatekeepers

The gate-keeping function police serve for PwMI in crisis situations has become more pronounced since deinstitutionalization of state hospitals in the U.S. and abroad (Lamb & Weinberger, 2014), and the sub- sequent inability of community-based treatment providers to service the growing population of PwMI (International Association of Chiefs of Police, 2010; Slate et al., 2013). State statutes that prescribe more rigorous criteria for civil commitment to state hospitals have also raised the visibility of PwMI. Lack of community support for PwMI and stigma, coupled with inadequate dispatch training and policies on best practices for navigating police encounters for PwMI, can result in greater use of incarceration for PwMI for minor offenses (International Association of Chiefs of Police, 2010; Slate et al., 2013).

With increasing interactions between police and PwMI, current programs seek to provide pre-book- ing diversion options that may address underlying issues and/or needs related to PwMI more effec- tively. Programs and their variations fall under three categories: (a) mental health-based specialized mental health responses; (b) police-based specialized mental health responses; and (c) police-based specialized police responses (Slate et al., 2013). This study is focused on CIT as a specialized police response in one jurisdiction.

280 M. P. BRATINA ET AL.

CIT training

The CIT model was designed to improve police response to PwMI. It is the most widely adopted specialized police-based training program in the United States (Gostomski, 2012; Watson, Ottati, Draine, & Morabito, 2011). It has been implemented in Australia, Liberia, New Zealand, Canada, and the United Kingdom (Hartford et al., 2006; Kane, Evans, & Shokraneh, 2017; Kohrt et al., 2015; NSW Police Force, 2014). The CIT model originally was conceived in the aftermath of a 1987 incident in Memphis, Tennessee that resulted in Joseph Dewayne Robinson – a man with a history of mental health and substance abuse issues – being fatally shot during a crisis encounter. When police arrived at the scene, Robinson was wielding a knife and appeared to be cutting himself. After failing to desist and release the weapon, Robinson allegedly began to approach police and was subsequently shot eight times (Heilbrun et al., 2012). In response, a community task force comprised of law enforcement, community mental health providers, addiction professionals, and consumer advocates was established. The members collaborated and designed the CIT model (Heilbrun et al., 2012; Watson et al., 2011). Prior to implementation of CIT, most police departments, including the Memphis Police Department, were only offering a few hours of academy-based training in crisis intervention (Gostomski, 2012; Pearson, 2014).

Current estimates suggest that there are approximately 3000 CIT programs in the United States (Taheri, 2016; University of Memphis, n.d.). CIT implementation globally has also been underway, and evaluation research has been published (Kohrt et al., 2015; Taheri, 2016). Objectives of the original Memphis CIT model include: (a) advanced training, (b) immediate crisis response, (c) safety of officer and consumer, and (d) proper care for persons in crisis (Pennsylvania Mental Health & Justice Center for Excellence, 2013). Police agencies that have implemented CIT report positive results (DeMatteo et al., 2013; Pearson, 2014; Steadman, Deane, Borum, & Morrissey, 2000).

Under the Memphis model, patrol officers complete a one-time, 40-h (full week) training curricu- lum in how to respond to citizens in crisis (Pennsylvania Mental Health & Justice Center for Excellence, 2013). Various training modules are facilitated and delivered by law enforcement personnel, mental health professionals, family and consumer advocates, and experts in related fields. As presented in Table 1, training sessions cover topics including: (a) signs and symptoms of mental illness, (b) types of psychotropic medications, (c) de-escalation techniques, and (d) interaction with PwMI who are not currently in crisis. Two essential elements of the model are officer training and the development and maintenance of criminal justice-mental health partnerships (CIT International, 2011). Successful implementation of training elements should produce changes in officers’ (a) attitudes (i.e., decreased social distance from PwMI, confidence when responding to calls involving a mental health crisis, and responsiveness regarding recognizing the appropriate treatment), (b) knowledge (i.e., of the origins and effects of mental illness and the available resources/services in the jurisdiction), and (c) skills in de-escalation techniques for crisis situations. The model purports to affect subsequent behavior of trained officers when encountering PwMI (i.e., reduction of injuries to consumer and officer and increased diversion) (CIT International, 2011; Cross et al., 2014).

CIT is more than training. One of its most important design and implementation factors is collab- oration and shared knowledge of community resources (Slate et al., 2013). In addition to the inter- section of mental health and criminal justice systems, many systems share clients, including public welfare, veterans’ affairs/services, substance abuse, and foster care or dependency. Developing strong partnerships between stakeholders allow forensic-based case managers, re-entry coordinators, and first responders to make referrals to community providers (e.g., mental health and drug and alcohol). Collaboration among parties involved with a consumer of mental health services can ensure proper services are being implemented, save resources and funding, and provide on-going evaluations. Due to limitations in available data, this element of CIT is not examined in the present study.

Consistent with its multi-systemic theme, most CIT law enforcement officials confer with com- munity stakeholders when planning and delivering training. Involved stakeholders often include: (a) substance abuse and mental health service providers, (b) advocates in the community, (c) PwMI, and

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(d) family members of PwMI (Pennsylvania Mental Health & Justice Center for Excellence, 2013). Attendees are a diverse group of first responders and include (a) corrections officers, (b) school resource officers, (c) police and deputy sheriffs, (d) public safety dispatchers, (e) 911 operators, and (f) medical and mental health professionals. Most trainees are self-selected volunteers or recommended by their departments (Thompson & Borum, 2006). An increasing number of jurisdictions require recruits and veterans to complete the full 40 h of CIT training. Consequently, more valid observations will be possible in future analyses of the program (Cross et al., 2014; Pennsylvania Mental Health & Justice Center for Excellence, 2013).

For CIT based on the Memphis model, the training curriculum may vary depending on the resources available in the community. For example, in some areas (such as the one under study), trainees have the opportunity to make a site visit to a mental health or other specialty court (e.g., drug court) as part of the training. In more rural areas without similar programs, the agenda differs and issues facing that community, such as substance abuse, might be emphasized.

Effectiveness of CIT

CIT programs are successful in (a) improving understanding of signs and symptoms of mental illness, (b) reducing stigma and negative attitudes toward PwMI, and (c) increasing the number of positive police interactions with PwMI overall (e.g., Compton et al., 2006; Wells & Schafer, 2006). For exam- ple, Compton and colleagues (2006) administered a pre-posttest survey to police officers prior to and directly following a 40-h CIT training to determine changes in officers’ knowledge, attitudes, and social distance, particularly related to persons with schizophrenia. In their study, 159 officers completed the surveys, and findings revealed that officers reported a decline in stigmatizing attitudes toward persons with schizophrenia, including improved attitudes regarding their levels of aggressive behavior (i.e., potential threat). Officers also indicated enhanced knowledge about the disorder, improved attitudes in support of local treatment programs for persons with schizophrenia, and a decreased desire for social distance from persons with schizophrenia.

CIT also appears to be effective in diverting PwMI to mental health treatment as opposed to processing in the justice system. Watson et al. (2011) examined data from 112 officers within four contextually distinct (i.e., populations and availability of mental health resources were clearly differ- ent) Chicago police districts where about half the officers were CIT trained with the Memphis model. On four occasions following their training, officers were asked a series of questions to measure the effectiveness of CIT training. Findings indicated that CIT trained officers in areas with many mental health service providers directed a higher number of PwMI to services rather than making an arrest. In districts where few alternative resources existed, there was little difference between CIT and non- CIT trained officers.

Studies on CIT programs outside the U.S. reveal similar findings For example, in one pre/post-test evaluation of a CIT curriculum developed specifically to improve and strengthen collaboration between law enforcement and mental health service providers in Liberia, Kohrt and colleagues (2015) found a significant increase in knowledge of and positive attitudes toward PwMI, and a significant decrease in social distance reported by officers who completed an adapted 3-day version of CIT. Similar to Watson et al. (2011), Liberian police officers were more likely to divert people to treatment instead of jail after the training.

Other research suggests that CIT has (a) reduced arrests (e.g., Steadman et al., 2000); (b) increased the number of mental health related calls identified (e.g., Teller, Munetz, Gil, & Ritter, 2006); and, (c) facilitated diversion to mental health treatment services (Compton, Bahora, Watson, & Oliva, 2008; Heilbrun et al., 2012; Lattimore, Broner, Sherman, Frisman, & Shafer, 2003). Findings are incon- clusive regarding improvements in overall public safety, which refers to reductions in use of force by and against police and resulting injuries to consumers and/or responding officer(s) (Morabito & Socia, 2015; Taheri, 2016). Cowell, Broner, and Dupont (2004) reported that PwMI diverted through CIT indicate a greater reduction in symptoms related to their mental illness, although there was no

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significant reduction in the likelihood of reoffending. They found that PwMI diverted from the system through a pre-booking diversion program (e.g., CIT) utilized mental health services in the 12 months following the diversion.

Much of what has been measured regarding CIT effectiveness has been attitudinal, and overwhelm- ingly, there is little data pertaining to changes in police behavior. The Franz and Borum (2010) study filled this gap. Using CIT-encounter tracking forms from nine police agencies in a large, primarily urban, county in central Florida for five years (2001–2005), they examined dispositional data from 1,539 encounters between CIT-trained officers and PwMI. Specifically, they compared the number of arrests vs. ‘prevented’ arrests (diverted cases that officers reported would have likely resulted in an arrest prior to their CIT training). Findings indicated that CIT prevented a substantial number of PwMI from being arrested while in crisis (i.e., only 3% of CIT calls resulted in an arrest, and 19% of CIT calls examined would have resulted in arrest prior to the officer being trained in CIT – all other calls resulted in diversion to mental health referrals and/or services).

Purpose of this study

This study’s primary aim is to update the current literature by describing specific elements of encoun- ters between CIT-trained police and citizens experiencing mental health crises in one jurisdiction in Florida. Particularly, the present study extends the Franz and Borum (2010) research by examining the characteristics of cases/consumers, the outcomes/dispositions, and the characteristics of diversion cases in south Florida in which officers reported that they would have taken the consumer to jail if they did not receive CIT (i.e., ‘prevented’ arrests). Furthermore, this study attempts to help address a gap with research that collects and examines data specific to law enforcement encounters with PwMI (Morabito & Socia, 2015). The research questions guiding this study are:

(1) What are the outcomes/case dispositions of CIT encounters in this jurisdiction? How do the outcomes compare with those from previous research conducted in Florida (i.e., Franz & Borum, 2010)?

(2) What are the characteristics of the jurisdiction’s cases/consumers being diverted? (3) How do police perceive they would have responded to the situation prior to CIT; what are

the factors influencing their perception?

Based upon these questions and published research, we anticipated a high-level of diversion from the system.

Method

The research approach was a descriptive case-study design of one jurisdiction comprised of a four- county area in south Florida. The decision to deploy CIT-responders is typically made by the dispatch- ers, although others may request officers specifically trained in crisis intervention or de-escalation with special populations. These data include a sample of police encounters in which the dispatcher radioed for CIT-trained police to respond to a situation that may have involved a PwMI in crisis. The dispositions of encounters between CIT officers and PwMI were examined as a means of estimating the number of cases diverted to mental health evaluation and treatment vs. arrest. Although unable to obtain access to additional cases from the jurisdiction to demonstrate officers’ pre-CIT arrest dis- positional outcomes (or cases in which a specialized response was not required) to examine differ- ences in dispositions, the results can inform the field by showing how some programs are operating procedurally.

The data-set included CIT calls from four different law enforcement agencies in the jurisdiction from 2007 to 2011.2 Official self-reported behavioral health data for 2008–2010 at the jurisdiction-level indicate that an estimated 4.8% of adults (18 and older) had been diagnosed with serious mental illness3

M. P. BRATINA ET AL.284

during the year prior to the survey (SAMHSA, 2014). With respect to suicide ideation, estimates show that approximately 4% of adults had contemplated suicide seriously during the same period. For this study, all data are analyzed and reported in aggregate form.

CIT in selected jurisdiction

The jurisdiction is part of the Florida CIT Coalition that was established in 2004. The Coalition con- sists of stakeholders from diverse counties whose goal is to develop consensus on CIT for the State of Florida to ensure that the training can achieve maximum effectiveness. According to the Florida CIT Program Model,4 essential elements based on the original Memphis Model must be included in the curriculum to maintain fidelity to achieve effective training outcomes. Original Coalition members included representatives from mental health providers, law enforcement agencies, and advocates from 13 counties, including Broward and Dade. As of February 2015, the Coalition members represented 23 counties – including the regional site for this study (Florida CIT, 2015).

Key stakeholders The University of Memphis (n.d.), CIT Center, recommends developing a steering committee with members from various agencies who advocate across systems of care in the community (Dupont, Cochran, & Pillsbury, 2007). The group’s primary responsibility is to assist with the planning stages of the program, and to sustain the core of the training from its inception. The CIT Steering Committee is comprised of mental health and criminal justice representatives from the jurisdiction, including law enforcement (county, city, and regional police), corrections officials (jail director of the largest county, and Chief Executive Officer and supervisory staff from secure forensic hospitals/detention centers), state-level mental health and substance abuse personnel from the local Department of Children and Families, and the National Alliance on Mental Illness (NAMI) or other advocates. The multiagency characteristic reflects one of the three core elements of a successful CIT program: The development of ongoing partnerships (Dupont et al., 2007). One Steering Committee member is designated as the CIT-Coordinator whose primary task is to coordinate presenters, location, and curriculum updates for each 40-h (full week) program. The Coordinator also is the lead facilitator for the training; and typically, the other members of the Committee are involved only in planning (though some facilitate training modules periodically and/or attend graduation on the last day of training).

Participants and data collection

In this jurisdiction, training is offered three times per year, and each training cohort group has approx- imately 30–35 attendees. During the years for this study (2007–2011), approximately 650 police officers were trained in CIT using the Memphis Model. As noted and consistent with the Florida CIT Program Core Elements, trainees (mostly patrol officers and corrections staff) are selected from candidates who have either volunteered or are recommended (some mandated) by their departments.

The departments requested that CIT-trained police officers who respond to mental health-related crisis calls complete documentation forms immediately following any encounter. The dispatcher, adher- ing to the jurisdiction’s protocol, determines whether a call is dispatched as involving a mental health or psychiatric crisis. However, the data collection instrument utilized did not contain this information. There were 438 documented encounters reported by four departments with approximately 113 CIT trained officers (21 out of 438 documented encounters did not include legible officer names or badge numbers) from 2007 to 2011. Of these 438, 33 encounters were excluded from the analysis due to missing variables; a total of 405 encounters comprise this study (N = 405).

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Instrumentation

Officers trained in CIT complete the target jurisdiction’s Crisis Intervention Tracking Form (CIF; Appendix 1) following encounters. Department administrators distribute forms to CIT-officers only, and they are requested to complete one for each encounter. However, there is no way to determine officer compliance. Therefore, it is more accurately described as ‘voluntary’. The CIF contains 11 sections which officers complete. The first section asks the officer for basic demographic information about the consumer and encounter details. The second section includes 10 checkboxes for officers to indicate the phrases describing the nature of the incident. In the third section, the officer enters infor- mation about the consumer’s use or possession of a weapon. Sections four and five solicit information about officer’s prior contact with the consumer and evidence of drug and/or alcohol intoxication. In sections six and seven, the officer provides information specific to elements of the consumer’s mental health status (i.e., mental health referral and medication compliance). For section eight, the officer indicates all outcomes of the encounter. The ninth section requests information about use of force (i.e., whether force was employed, and, if yes, whether any resulting injuries to the officer and/or the subject occurred). The tenth and eleventh sections are specific to the CIT-officers – questions aimed at assessing the officers’ perceptions and asking them to reflect on whether they would have taken the consumer to jail prior to CIT and soliciting identifying information, such as their name and badge number. Notably, officers complete the forms post-encounter, and aside from factual data presented by dispatch and at the scene of an incident (e.g., consumer name, date of birth, diagnosis – if reported), responses reflect officers’ perceptions and discretion.

Study respondents indicated whether force was used during an encounter by checking a box labeled ‘yes’ or ‘no’ For this data-set, ‘use of force’ is defined as any type of force along the continuum (from officer presence to lethal force) (National Institute of Justice, 2009). Subsequent injury because of use of force was also indicated using a binary variable (i.e., officers were asked to indicate injuries to self or subjects via a checkbox option of ‘yes’ or ‘no’ for each), thereby limiting information on injuries incurred during encounters.

Results

Characteristics of cases/outcomes

Of 405 documented CIT encounters, 85% (n = 346) of cases were diverted from the system. Descriptive analysis and bivariate patterns reveal (see Table 2) that among the diversion cases, about 12% (n = 47) of cases were ‘prevented arrests’ (i.e., officers reported they would have taken the consumer to jail if they did not receive CIT), and only 1% (n = 5) of encounters resulted in an arrest. The small number of cases that resulted in arrest or ‘no action’ precluded statistical inferences to be drawn Of the 47 ‘prevented arrests’ cases, officers indicated which charges they might have utilized. Responses varied, but more frequently involved battery charges (n = 17), disruption to the public order (public intoxica- tion, disorderly conduct, misuse of 911) (n = 14), and resisting arrest (n = 4). The most serious charges considered for imposition were aggravated assault (n = 1), burglary attempt (n = 1), and grand theft (n = 1). These data suggest that CIT may facilitate officers making more referrals to agencies rather than formally processing individuals through the system.

Table 2 indicates that all subjects who encountered CIT-trained officers were relatively evenly distributed by gender, with male clients representing 55.9%, and female clients representing 44.1% of the sample. Officers identified the largest percentage as White (83.1%); 14.6% as Black, and 2.3% as Hispanic. It is worth noting that a trend in reporting race data on surveys demonstrates that the race of Hispanics or Latinos is frequently reported as White (Cohn, 2014; Ennis, Rios-Vargas, & Albert, 2011; Rios, Romero, & Ramirez, 2014). The sample ranged from age 12 and under to 65 and over. The two largest categories were between the ages of 25–29 and 40–44, and each group represented 12.3% of the sample Together, these two groups comprised 25% of the citizens involved in CIT encounters.

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The mean age was 35.8 years of age. Overall, youth (12 and under) and older individuals (60 and older) were less likely to have an encounter with CIT-trained police.

Either the subject or someone who knew him/her and was on the scene reported the diagnosis. In three quarters of overall encounters (75%), the officer noted the ‘diagnosis’ was unknown; and in the remaining 25% of cases where the diagnosis was known, it was not always categorized. Of the diagnoses reported, bipolar disorder had the highest frequency at 7.6%. Other categories included Depression, Schizophrenia, PTSD, and ‘Other’.

In terms of incidence time, a slightly larger percentage of cases occurred between the hours of 12 and 6 pm (38.5%), followed by 32.8% of cases occurring between 6 pm and midnight. By contrast, for these cases, mental health crisis calls were least likely to be reported in the study jurisdiction after

Table 2. Bivariate patterns for four-category case disposition variable by demographic characteristics and incidence characteristics.a

notes: Bold numbers = values that are above the overall mean of total for a particular variable. aall numbers are percentages except for mean age. bdiversion cases with which officers reported that they would have taken the consumer to jail prior to cit. csome cases reported more than one category for ‘nature of incident’.

 

Case disposition

Total (N = 405) No action (N = 7) Arrest (N = 5) Prevented arrestsb

(N = 47) Diversion (N = 346)

Demographic characteristics Race White 83.1 57.1 60.0 79.2 84.4 Black 14.6 42.9 40.0 16.7 13.5 hispanic 2.3 0.0 0.0 4.2 2.1 Gender Male 55.9 42.9 60.0 66.7 54.8 Female 44.1 57.1 40.0 33.3 45.2 Age 35.8 46.9 30.0 33.9 35.9 Diagnosis Unknown 75.1 42.9 80.0 62.5 77.2 Bipolar disorder 7.6 0.0 20.0 16.7 6.4 depression 6.6 0.0 0.0 8.3 6.6 schizophrenia 3.7 42.9 0.0 0.0 3.4 Ptsd 0.9 14.3 0.0 2.1 0.5 other 6.2 0.0 0.0 10.4 5.8

Incident characteristics Incident occurrence time after 12am–6am 10.4 0.0 20.0 10.6 10.4 after 6am–12pm 18.3 42.9 20.0 10.6 18.8 after 12pm–6pm 38.5 14.3 60.0 40.4 38.4 after 6pm–12am 32.8 42.9 0.0 38.3 32.4 Nature of incident disorderly/disruptive behavior 4.2 14.3 33.3 2.1 4.0 nuisance 0.2 14.3 0.0 0.0 0.0 threats or Violence to others 3.0 0.0 0.0 6.4 2.7 theft/Property crime 0.5 0.0 0.0 2.1 0.3 neglect of self-care 3.9 0.0 0.0 2.1 4.3 Public intoxication 2.3 0.0 0.0 4.3 2.1 drug-related offense 0.5 0.0 0.0 0.0 0.5 suicide threat/attempt 45.8 0.0 0.0 4.3 52.3 other 7.2 57.1 0.0 4.3 6.7 Multiple offensesc 32.4 14.3 66.7 74.5 27.2 Weapon Yes 13.5 0.0 20.0 16.7 13.2 no 84.0 100.0 80.0 77.1 84.7 Unknown 2.5 0.0 0.0 6.3 2.1 Drug/Alcohol  Yes 38.6 0.0 20.0 43.8 38.9 no 61.4 100.0 80.0 56.2 61.1

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12:00 am up until 12:00 pm (After 12–6am = 10.4%; Between 6am-12 pm = 18.3%). With respect to nature of the incident, 45.8% of documented encounters were a result of a reported suicide threat/ attempt. The second most frequently documented reason was some combination of incident charac- teristics – coded as ‘multiple offenses’ – making up 32.4% of encounters. Conversely, cases involving theft/property crime represented less than 1% of encounters. In the majority of incidents (84%), no weapon was involved, and officers reported drug or alcohol involvement in 38.6% of the cases. Again, the nature of the incident reported for each encounter is determined by the responding CIT officer.

Case dispositions of diverted CIT encounters

As presented in Table 2, we disaggregated the cases into four categories: arrest, no action, diversion, and diversion but jail prior to CIT. Using the data sheets, officers were asked to reflect retrospectively and indicate whether they would have taken the consumer to jail prior to receiving CIT by selecting ‘yes’ or ‘no’. Of the 393 diverted cases, in 346 cases, officers indicated that they would have diverted even prior to CIT, while in the remaining 47 cases officers reported they diverted because of CIT. As indicated in Table 2, of 346 cases diverted according to the reports (where arrest prior to CIT was not considered), 84.4% of consumers were White and 13.5% were Black. For gender, the percentage of male and female cases diverted were relatively evenly distributed, though males were diverted at a slightly higher percentage (54.8% vs. 45.2%, respectively); however, the number was above the mean for female cases in the overall sample. The average age of individuals diverted was 35.9.

For the variable, diagnosis, ‘unknown’ was the most frequently occurring value among cases with a diversion outcome (77.2%). The value was slightly above the mean for cases representing an unknown diagnosis in the sample. With respect to time of encounter, two periods, 12:00 pm–6:00 pm, and 6:00 pm–12:00 am (38.4% and 32.4%, respectively), occurred the most frequently under the diversion outcome. The number of cases between 6:00 am and 12:00 pm was above the mean as reported for the overall sample, but only slightly.

In relation to the association between nature of the incident and a diversion decision by the officer, the most frequent type of incident was threat or attempted suicide (52.3% of cases), followed by mul- tiple offending behaviors (27.2%). The value for suicide cases with a diversion outcome was above the mean for cases representing suicidal ideation and behavior, indicating (as expected) that officers were more likely to divert consumers when the call was related to a threat or attempted suicide.

When no weapon was present, the officer, in 84.7% of cases, diverted individuals. When alcohol or drugs were involved, officers diverted the individual in 38.9% of the cases. The value of diversion cases not involving weapons was slightly above the overall mean for the weapons variable; and for drugs and alcohol, the percentage of cases in which there was a diversion outcome was only slightly above the sample mean

Diversion but Jail Prior to CIT Of 47 cases in which police indicated that they would have made an arrest prior to the training pro- gram, respondents reported that they would have arrested and placed in jail 16.7% of Black and 4.2% of Hispanic individuals. Both values are above the overall mean for the race variable. For gender, the percentage of males in which an arrest would have been made prior to CIT is higher than females (66.7% vs. 33.3%, respectively), and it is also above the mean for cases representing males in the sample. The average age among individuals with a jail outcome was 33.9.

Finally, of 47 cases in which officers indicated that they would have made an arrest prior to CIT, a weapon was present in 16.7% of cases, and alcohol or drugs were reported in 43.8% of these cases. The value of cases involving weapons was above the overall mean for the weapons variable in this sample. Furthermore, the value of the ‘unknown’ weapon category (6.3%) was also above the mean for the weapons variable. For the drugs and alcohol variable, in which police indicated an arrest would have been made when drug or alcohol involvement was reported, 43.8% was above the mean in the overall sample.

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For the diagnosis variable, the most frequent category under arrest prior to CIT is ‘unknown’ (62.5%); and the least occurring value is schizophrenia (0.0%). Values for categories of bipolar (16.7%), depression (8.3%), PTSD (2.1%), and ‘Other’ (10.4) were above the mean for cases representing these diagnoses in the sample. This finding is corroborated with logistic regression analysis. As demonstrated in Table 3, none of the demographic characteristics is statistically significant, and considering both the statistical significance as well as the effect size, there is no race effect. Although some variables are statistically not significant, their effect sizes are noteworthy and may warrant future examination [(i.e., depression (Exp(b) = 2.005), PTSD (16.081), and theft/property crime (2.196)]. Moreover, officers in the current study were almost 16 times more likely to divert cases involving PTSD after the CIT training, and approximately twice as likely for cases involving depression or theft/property crimes.

The time zone variable is the most robust in differentiating this disposition outcome. And the nature of the incident also shows a negative effect in the model. Specifically, even without CIT, officers are more likely to divert cases occurring between 6:00 am and 12:00 pm, and suicide threat/attempt cases. Thus, CIT has little impact on these cases.

Discussion

Consistent with Franz and Borum (2010), the majority of encounters documented by CIT-trained officers resulted in diversion rather than arrest. Whether this is the direct result of CIT is unclear, but it suggests the outcome one would expect after the training. At the very least, it appears that CIT officers have knowledge of diversion options and they often make referrals instead of arrests. There were other study findings, however, that may add to the literature on CIT, and encourage future studies. First,

Table 3. logistic model by case disposition (N = 393).

notes: Model chi-square = 73.532***; cox-snell R2 = 0.183; nagelkerke R2 = 356. Male, White, unknown diagnosis, after 6 pm–12am, and multiple offenses are the reference category for each variable. adiversion cases with which officers reported that they would have taken the consumer to jail prior to cit. *p < 0.05; **p < 0.001.

 

Jail prior to CITa vs. Diversion

b SE EXP (b) Gender −0.335 0.391 0.715 Race Black −0.124 0.536 0.884 hispanic −0.125 0.331 0.883 age −0.007 0.012 0.993 Diagnosis Bipolar disorder 0.36 0.591 1.434 depression 0.696 0.701 2.005 schizophrenia −19.124 7.011 0.000 Ptsd 2.774 1.563 16.018 other 0.221 0.636 1.247 incident occurrence time after 12am–6am −0.497 0.659 0.608 after 6am–12pm −1.568* 0.674 0.208 after 12pm–6pm −0.314 0.43 0.73 Nature of incident disorderly/disruptive Behavior −1.622 1.102 0.197 threats or Violence to others −0.413 0.872 0.662 theft/Property crime 0.787 1.523 2.196 neglect of self-care −1.725 1.11 0.178 Public intoxication −0.501 0.847 0.606 drug-related offense −19.847 4.982 0.000 suicide threat/attempt −3.790*** 0.772 0.023 other −1.335 0.799 0.263 Weapon −0.495 0.525 0.610 drug/alcohol 0.185 0.421 1.203 constant 0.131 0.718 1.140

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similar to Franz and Borum (2010) this study found a substantial proportion of ‘prevented arrests’ when officers were CIT-trained. While acknowledging this as an improvement, it is important to note that in 88% of the cases, officers reported that they would have taken the same actions even if they had not completed CIT training.

CIT has been promoted as a way to address stigmatization of mental illness and reduce the num- ber of criminal justice-related encounters that result in arrest or injury to all parties involved (CIT International, 2011). The desired outcome of these encounters should be successful diversion to quali- fied mental health services. Training does not guarantee that first responders will become advocates and have an understanding of mental health issues, but the emerging research indicates that CIT trained individuals may be less likely to have stigmatizing attitudes about persons with mental health issues, more likely to understand mental health needs, and more likely to divert individuals from further immersion in the criminal justice system than those who are not trained (Cross et al., 2014). For the 47 cases, these data suggest that further immersion (use of jail) did not occur.

Additional evaluation of the CIT program that may translate into further development with CIT and/or other training opportunities or in collaboration with other regions across the state is needed. The goals of CIT include officer safety and diversion efforts to keep people with serious mental illness, who do not need to be in the criminal justice system, in the community. The results suggest that CIT should continue to be implemented and more robust research should be conducted as to its effective- ness – particularly in the context of these overall program objectives.

Formal studies on the effectiveness of CIT suffer from methodological issues (Taheri, 2016). Specific and pervasive difficulties include: (a) small sample sizes, (b) lack of a comparison group, and (c) selection effects which render conclusive findings and differences observed between groups prob- lematic (Cross et al., 2014; Engel, 2015). As noted, this study has limitations. Specifically, there was no comparison group and no data available prior to the implementation of CIT. Further, because participation in CIT for most officers is voluntary, there is a potential for selection bias, which could influence outcomes. Variation on these and other factors would have facilitated more sophisticated analyses and possible application to a wider audience.

Given recent attention on mental health issues in the criminal justice system, research involving police-citizen encounters has important policy implications. First, national data indicating that jails and prisons incarcerate disproportionate numbers of individuals with severe and persistent mental illness who are without proper treatment or care (Fellner, 2015; International Association of Chiefs of Police, 2010; National Alliance on Mental Illness, 2013a; Subramanian, Delaney, Roberts, Fishman, & McGarry, 2015; Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010) is discussed with greater urgency. Thus, the finding that the large majority of CIT encounters in this particular jurisdiction resulted in diversion rather than arrest, even if temporarily, is encouraging. It suggests that training is occurring in the region and it is effective in terms of increasing awareness and knowledge pertaining to mental health and available resources.

Previous research demonstrated support for the idea that police perceive CIT training to be effective when it is accompanied by a supportive community with accessible resources and positive relationships between law enforcement and community human service providers (Cross et al., 2014; Watson et al., 2011). To gauge the impact of such factors in the future, an assessment of police-provider relationships, from the perspectives of providers, law enforcement officials, and consumers would be beneficial. In studying CIT, researchers have designed questions that measure factors pre and post-training after having encountered consumers: Officers’ personal familiarity with mental illness; perceptions of the mental health services available in the area; their own skills for responding to persons with mental illnesses; their perception of the CIT program; and district organizational support of the CIT program (Compton et al., 2006). Finally, it is recommended that data evaluating consumer perspectives be incorporated in evaluating the overall effect of CIT training.

As noted, participants were not evaluated regarding their attitudes and behaviors prior to training. Furthermore, the study included only four of nine police localities in this region. The five localities that did not submit data might have had different outcomes. Nonetheless, the study is relevant; and

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it is useful to consider and discuss policy and practice regarding more successful police encounters with PwMI across systems.

Future directions

There are several recommendations for future research. First, once appropriate measurement tools are constructed, researchers should survey a diverse sample of departments to further explore the relationship between CIT and positive outcomes in terms of diversion. Similarly, because it is not clear whether individual officers differ with respect to the method by which they received the training (i.e., volunteered to participate in the training or assigned), their arrest (i.e., encounter) histories, or other characteristics that might influence attitudes and behavior (e.g., race, age, years of service, level of education, available community resources), the relationship should be further explored by comparing outcomes between officers and other participants.

Second, future researchers might develop a tool that more directly measures the effectiveness of CIT elevating the training from a best practice to an evidence-based practice. As noted, it is possible that CIT training alone does not predict successful outcomes in terms of diverting consumers from the criminal justice system. Earlier research indicates that other constructs, such as organizational factors, mental health resources, and community characteristics, when considered with officer char- acteristics, may provide a more comprehensive picture as to the way a community responds to PwMI (Cross et al., 2014). However, measuring additional outcomes other than those that the jurisdiction is already utilizing to obtain more information as to the influence of CIT training on individual officer decision-making would be helpful.

Third, mental health issues affect people in every culture. CIT may have international applicability to promote effective collaborations in a global context. In particular, the adaptive nature of the Memphis model enables it to be applied to locations with varying needs and resources. Notwithstanding this advantage, minimal attention has been focused on implementation of CIT internationally. Furthermore, existing research – mostly conducted in the U.S. – fails to compare outcomes between communities within geographic regions (e.g., rural vs. urban communities). Perhaps future research could include comparative analyses of outcomes between the U.S.-based CIT program and other versions that have been implemented successfully in other countries (e.g., Woods, Leidl, Butler, Stonechild, & Luimes, 2017 [Police and Crisis Team]). More evidence to understand which approaches communities can adopt to address barriers to successful implementation is essential – both internationally and domestically.

Notes 1. The ‘Memphis Model’ of CIT training, while the original format and the most replicated, is not the only model

used across the United States (Cross et al., 2014). 2. Nine police departments in the jurisdiction participate in the area’s Crisis Intervention Team (Florida CIT,

2015); however, for reasons unknown to the researchers, five departments did not submit completed data sheets for analysis.

3. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines serious mental illness: ‘Serious mental illness is defined as having a diagnosable mental, behavioral, or emotional disorder, other than a developmental or substance use disorder, that met the criteria found in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and resulted in serious functional impairment. (SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2008, 2009, and 2010 (Revised March 2012).

4. The Florida CIT Coalition has published a document that outlines the ‘Florida CIT Program Model’ (http:// www.usf.edu/cbcs/mhlp/tac/documents/cj-jj/cj/florida-cit-program-2005.pdf) Core elements of the program (The Model) are aligned with those set forth in the original Memphis Model, and include policies and procedures related to using a generalist/specialist model; selection of CIT officers after training; a recognizable CIT pin worn by trained officers; size of CIT force; selecting a CIT Coordinator; selecting a mental health/substance abuse Coordinator; representation of mental health advocacy organizations; mental health and substance abuse systems; roles and responsibilities of law enforcement and service providers in the system of care; frequency of training and selection of trainers/presenters; refresher courses and abbreviated versions of training for other

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community stakeholders; methods for collecting data on program outcomes; ongoing meetings and support, feedback; and, recognition of officers (Florida CIT, 2015).

Disclosure statement No potential conflict of interest was reported by the authors.

Notes on contributors Michele P. Bratina, PhD, is an Assistant Professor in the Criminal Justice Department at West Chester University in West Chester, Pennsylvania.  Previously, she was the Forensic and Children’s Mental Health Coordinator for the Florida Department of Children and Families in the 19th Judicial Circuit. Dr Bratina is the Immediate Past President of the Northeastern Association of Criminal Justice Sciences (NEACJS). She is also a three-time recipient of the ACJS/Sage Junior Faculty Professional Development Teaching Award.  Her research interests and publications include human exploitation, criminological theory, race, social structure, ethnicity and crime, and forensic mental health. Dr. Bratina has authored two books, Latino attitudes toward violence: The effect of Americanization (LFB Scholarly Publications, 2013), and Forensic mental health: Framing integrated solutions (Routledge-Taylor & Francis, 2017). She also has pub- lications in the Journal of Criminal Justice Education, the Journal of Ethnicity in Criminal Justice, and the International Journal of Police Science and Management.

Kelly M. Carrero, PhD, BCBA is an assistant professor in the Department of Psychology & Special Education at Texas A & M University - Commerce. She earned her doctorate in special education with an emphasis on behavioral disorders at the University of North Texas. Prior to entering academia, she served children from culturally and linguistically diverse backgrounds identified with exceptionalities and behavioral health concerns in a variety of settings. Her research projects serve as a vehicle for positive social change and advocacy for children identified with exceptionalities and challenging behaviors (including Autism Spectrum Disorders). Specifically, she is interested in identifying (a) demographic dis- parities in the special education evidence-base and provision of quality service delivery, (b) interventions that increase access to social capital for children and families from diverse backgrounds who are affected by communicative and behavioral health disorders, and (c) culturally responsive practices in research and service delivery. She serves her profession as a reviewer for several journals and an active member of the Council for Exceptional Children (CEC) and its respective divisions.

Bitna Kim is a professor in the Department of Criminology and Criminal Justice at Indiana University of Pennsylvania (IUP). She received her PhD in the college of criminal justice at Sam Houston State University, Texas. Her specific areas of interest include a systemic review of the interventions with Meta Analysis, police-community corrections partner- ships, and international/comparative criminal justice. She has published widely, including recent articles in Crime and Delinquency, Journal of Criminal Justice, Trauma, Violence & Abuse, Police Quarterly, Policing, Policing and Society, Federal Probation, Prison Journal, Criminal Justice and Behavior, Deviant behavior, Asian Journal of Criminology, and Journal of Criminal Justice Education.

Alida V. Merlo is a professor of Criminology and Criminal Justice at Indiana University of Pennsylvania. She received her PhD in Sociology from Fordham University. Her research interests are juvenile justice, criminal justice policy, and women and the law. She is the co-author with Peter Benekos of Reaffirming Juvenile Justice: From Gault to Montgomery (2018), and The Juvenile Justice System: Delinquency, Processing, and the Law, 9th Edition (2019). Her recent research has been published in the Criminal Justice Policy Review, the Journal of Criminal Justice Education, and the Asian Journal of Criminology.

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availability and district saturation on call dispositions. International Journal of Law and Psychiatry, 34(4), 287–294. Wells, W., & Schafer, J. A. (2006). Officer perceptions of police responses to persons with a mental illness. Policing: An

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Appendix 1. Crisis Intervention Tracking Form (CIF) from one judicial circuit in south Florida, 2014.

Crisis Intervention Form

Agency Case # ___________________________

Subjects Name: Date of Birth: Race: Sex:

Address: Arrival Time:/Completed Time:

City: State: Zip: Phone:

Enrolled in Medical Security Program? Yes No Unknown

Call Dispatched Self-Initiated Referred By: ____________________ Other: ___________________

Diagnosis: (if known) ___________________________________________________________________________

Nature of Incident (check all that apply) Disorderly/disruptive behavior

Neglect of self-care Public Intoxication Nuisance (loitering, panhandling, Trespassing Theft/other property crime Drug-related offenses Suicide threat or attempt Threats or violence to others No Information Other / specify:

Threats/Violence/Weapons Did subject use/brandish a weapon? Yes No Unknown If yes – Type of weapon (check all that apply): Knife Gun Other/specify:

________________________________ ______

Did subject threaten violence toward another person? Yes No Unknown If “yes”, to whom? (relative, law enforcement, stranger, Etc) ________________________________ ______

Did subject injure or attempt to injure self? Yes No

If Yes, how ___________________________

Prior Contacts (check all that apply) Known person (from prior LEO contacts) Yes No Unknown Repeat call (within 24 hours Yes No Unknown

_____________________________ ____

Drug/Alcohol Involvement Evidence of drug/alcohol intoxication Yes No Unknown If Yes – Alcohol Unknown Other Drug / specify:

Medication Compliance Yes No Unknown Specify if known:

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Disposition (check all that apply) No action taken/resolved on scent On-scene crisis intervention LEO notified case manager or

mental health center Outpatient/case management referral

Transported to treatment facility Facility: ______________________________ _________ Baker Act Marchman Act Arrested (if yes what charges)

Mental health referral Yes No

Use of Force Did incident result in a use of force? Yes No If yes, was there injury to the officer? Yes No Was there injury to the subject? Yes No ____________________________________________________________ _________________ Prior to CIT would you have taken this individual to jail Yes No

What would the charges have been? ______________________________________________

Signature of Officer: ___________________________________________________________

Print Officer Name: ___________________________________________________________

Badge/ID # ____________________________________________________________ _______

Agency: ____________________________________________________________ __________

Date: ____________________________________________________________ ____________

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