STUDY IN BLUE ANDGREY - CMHAStudy in Blue and Grey Background and Description of Project Police...

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Police Interventions with People with Mental Illness: A Review of Challenges and Responses

GREYSTUDY IN BLUE AND

BC DIVISION

Police Interventions with People with Mental Illness:A Review of Challenges and Responses

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Study in Blue and Grey

Canadian Mental Health Association BC DivisionDecember 2003ISBN 0-9698114-5-4

CMHA BC Division1200-1111 Melville St.Vancouver, BC V6E 3V6Tel: 604-688-3234Fax: 604-688-3236Email: [email protected]: www.cmha-bc.org

Study in Blue and Grey, Police Interventions with People with MentalIllness: A Review of Challenges and Responses was researched andwritten by Judith Adelman, PhD

Funded by grants as a result of the Direct Access Program of the BCLotteries Corporation (2001 - 2002) and grants from the Ministry ofHealth Services - Mental Health and Addictions Policy Division(2001 - 2003)

Directed by:Eric Macnaughton, MADirector, Policy and ResearchCMHA BC Division

Layout and Design by:Mykle Ludvigsen

Who are we?

The Canadian Mental Health Association, BC Division is a provincial charity that, for the past 50years, has worked to promote the mental health of all British Columbians and change the way weview and treat mental illness in BC.

We are part of a national association with over 80 years of experience. In BC, we have a networkof 20 branches across the province that provide direct service support for people with a mentalillness or a mental health problem including public education, rehabilitation services such as:supported housing, supported employment and education, clubhouses and community education.

At BC Division, our staff and volunteers focus on four major responsibilities: advocacy, publication, community-based research, and consumer empowerment programs.

www.cmha-bc.org

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Table of Contents

Background and Description of Project .............................................................................................. 4Outline of Report .............................................................................................................................. 4

Part One: The Nature of the Problem............................................................................................. 5Section A: Why Police are Interacting More with People who Have a Mental Illness ....................... 5

Changes in Models of Policing ..................................................................................................... 5Mandate ...................................................................................................................................... 5Changing Values and Styles of Policing ........................................................................................ 5

Section B: Barriers to Effective Interactions ..................................................................................... 6Inadequate advance information .................................................................................................. 6Inadequate Information Systems .................................................................................................. 6Lack of Adequate Information and Education about Mental Illness ............................................. 6Lack of Access to Consultation at the Scene ................................................................................. 7Lack of Responsiveness by Hospital Emergency Departments ...................................................... 7

Section C: Impacts of the Situation on People with Mental Illness ................................................... 7Criminalization ............................................................................................................................ 7Likelihood of Arrest Relative to General Population Depends on Severity of Crime ..................... 7Precipitating Factors of Arrest ...................................................................................................... 7Situations Where No Detention Is Made ..................................................................................... 8Injury or Use of Lethal Force ....................................................................................................... 8

Part One: Summary ......................................................................................................................... 9

Part Two: Solutions ...................................................................................................................... 10Section A: Situations and Actions that Precede Change ................................................................. 10Section B: Specialized Responses Involving Police and the Mental Health System .......................... 11

Model Prototypes ....................................................................................................................... 11Section C: Program Components Contributing to Success ............................................................ 13

Selection .................................................................................................................................... 14Training ..................................................................................................................................... 14Dispatch and Referral ................................................................................................................ 15Access to Information and Feedback .......................................................................................... 15Accessible Coverage ................................................................................................................... 16Access to Mental Health Services ............................................................................................... 16Mechanisms for Collaboration and Dispute Resolution Between Police and Mental Health Services ..17Measuring Outcomes ................................................................................................................. 17

Part Three: Conclusions and Recommendations ........................................................................... 18

Bibliography .................................................................................................................................... 20

Appendix 1: Outcomes .................................................................................................................... 22

Appendix 2: Other Non-Specialized Approaches to Achieving Collaboration ................................... 26

Appendix 3: Staged Intervention Continuum .................................................................................. 26

Appendix 4: Websites Providing Useful Information about Policing and Mental Illness ................... 28

Appendix 5: People Interviewed or Who Provided Information for This Project ............................... 28

Executive Summary....................................................................................................................... 30

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Background andDescription of ProjectPolice throughout North America are respond-ing to a significant number of 911 calls involv-ing people who have a mental illness. In the vastmajority of incidents, such calls are resolvedwithout incident. However, sometimes the re-sults are the death or injury of the police officer,the person who is ill, and/or another person.When this happens it has prolonged negativeeffects on the individuals and communities in-volved. When lives are lost, they cannot be re-claimed. Whether the result is injury or death,it has longstanding implications for the personswith mental illness, the family, police, and to allwho survive the incident.

In October 2000, the BC Chief Coroner is-sued a report following an inquest. A man whowas distressed and suffering from a mental ill-ness began acting violently in the emergencydepartment of a BC hospital. The police werecalled and as a result of the police action, theman was killed. The Coroner made a number ofrecommendations to various governments Min-istries. One of the Coroner’s many recommen-dations was that police be provided training withrespect to dealing with people with a mental ill-ness in a non-confrontational manner.

Because people are so complex and situationscan vary so significantly, it may not be possible toget to the point where there are no injuries ordeaths. However, the common vision requires thatwe look for ways to reduce injury and death byimproving the responses of the police and mentalhealth systems while recognizing already-existing,effective programs that make a difference.

Currently, there are a number of key reforminitiatives in various locations in North America.This paper is intended to build on that work byproviding relevant information regarding theseinitiatives that would enable the partners withinthe mental health and criminal justice systemshere in BC to plan more effectively, and to im-prove their system of response to people withmental illness who are in crisis.

The specific objectives of the project are to:• Find out what kind of training is offered to

police in different jurisdictions to deter-mine the common program elements, andto attempt to identify the most effectivecomponents

• Review the literature to determine whatservice delivery models are being used bypolice in various jurisdictions to intervenein crises

• Determine the impacts of the variousprograms: for example, whether they reduceinjuries, are helpful to people with mentalillness and to police etc.

• Examine recommendations from reviews ofpolice actions

• Determine key aspects and key strategies forimplementation; that is, those key factorsthat contribute to the establishment ofeffective intervention programs

This report relies on published research and re-ports, as well as interviews with individuals whowork for or with police departments, includingmental health professionals. It also includes in-formation gained from Coroner’s reports andinterviews with individuals who participated ininquiries.

Outline of the ReportPart One of the report looks at the nature of theproblem. It begins in Section A by looking atwhy more people with a mental illness are com-ing into contact with the police, describing anumber of factors that have contributed to thistrend, including changes in the mental healthdelivery system, changes within the police forceand the move towards ‘community policing.’Then, in Section B, the report looks at some ofthe factors that create barriers to effective policeresponse to persons with mental illness. Next,Section C looks at two key issues that have re-sulted from this state of affairs: criminalizationand injury or death of persons with mental ill-ness (as well as serious personal consequencesfor the police officers involved). The report thenexamines the factors that have caused police tochange their practices.

In Part Two, we look at solutions. Section Aof Part Two looks at different models of policeprograms that were developed to assist individu-als who are in psychiatric crisis, and identifiesthe common issues that each program addressesin various ways. Section B looks at available out-come research, including the relative strengthsand weaknesses of the models. In Part 3 we lookat conclusions and recommendations for actionin British Columbia.

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Part One: The Natureof the ProblemSection A: Why Police areInteracting More withPeople who have aMental IllnessDue to a number of factors common to mostof North America – such as cuts to long-termpsychiatric beds, improvements in treatment,and the philosophy of integration – morepeople with a mental illness live in the com-munity. Unfortunately, community supportshave not expanded proportionately to make upfor the loss of institutional services or for theincreased need brought about by an expandingpopulation.

In addition, existing community-based crisisresponse services – such as crisis lines, mobileafter-hours mental health teams, and crisis resi-dential facilities – are not well integrated andare limited in scope, particularly in rural areas.General hospital-based emergency services canalso be difficult to access due to bed reductions,and a tendency to offer treatment only to thosesick enough to warrant involuntary treatmentunder the Mental Health Act. As the BC EarlyIntervention Study found, individuals who seekhelp voluntarily from emergency wards in BCare often deemed ‘not sickenough’ to qualify for lim-ited acute care resources.The same study found that,in large part because of thesebarriers, over 30% of peoplewith serious mental illnesshad contact with the policewhile making, or attempt-ing to make, their first con-tact with the mental healthsystem.

Because of all the factors discussed above, thepolice are, by default, becoming the informal‘first responders’ of our mental health system,and are playing this role without the necessaryresources or support to carry it out properly. Theresults of this situation for people with mentalillness can be long delays in receiving treatment,

unnecessary trauma, violent incidents, andcriminalization that could have been preventedif care had been received earlier from the mentalhealth system. Estimates of the proportion ofuntreated mental illness in the criminal justicesystem range between 15 and 40%.

Changes in Models of PolicingThere has been ambivalence among police of-ficers as to whether dealing with situations in-volving mental illness falls under the traditionalpolice mandate. With changes in policing styles– including the move to ‘community policing’– has come increased contact and expanded re-sponsibilities of police officers in regards topeople with mental illness. Despite the poten-tial that these new policing models may repre-sent, these mixed feelings remain. This is becauseof the perception by police that the formal men-tal health system has shirked its own responsi-bility, and because of conflicts between new andmore traditional models of policing.

MandateThe police mandate consists generally of twoduties: to ensure safety and to provide protec-tion. This applies to interactions with membersof the general public and also applies to the waypolice interact with people who have a mentalillness. Despite this mandate, however, it is clearthat police are ambivalent about dealing withpeople with mental illness. Researchers in theUK, for example, found that some officers may

refuse to respond to a call in-volving a person with men-tal illness. They tended to in-terpret the call as a situationthat was solely the responsi-bility of the mental healthsystem, rather than one thatrequired them to protect orprovide safety for the personwith the illness.

Changing Values and Styles of PolicingAs mentioned, police departments are movingtowards community policing, where there ismore emphasis on problem-solving issues thatarise on the day-to-day police beat. In the con-text of mental illness, problem-solving mightentail an officer being able to recognize whenmental illness is at play in a given situation, de-

the police are, bydefault, becomingthe informal ‘firstresponders’ of ourmental health system

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escalating a situation, referring a person to ser-vices, or diverting an ill offender into treatmentrather than making an arrest.

With the increased emphasis on communityinvolvement has come greater contact withpeople with mental illness, and while the shiftto a problem-solving focus would seem to bepotentially useful in this context, the values oftraditional police work – emphasizing rules andprocedure, a tendency towards the use of forceto maintain safety, and a devaluing of attendingto non-criminal matters – may come into con-flict with new ideas about the responsibilities ofpolice officers towards people with mental ill-ness.

For example, though some officers indicate adesire to divert people with mental illness to themental health system, others may not feel it istheir job to be able to recognize that a given per-son in a potentially dangerous situation, in fact,has a mental illness. They may feel that the per-son with mental illness who commits a crimeshould be treated like any other offender.

Section B: Barriers toEffective InteractionsThere are a number of barriers that prevent po-lice from dealing more effectively with peoplewho have a mental illness. As discussed in theprevious sections, these challenges include gapsin community mental health services, and mixedfeelings about the nature of their responsibilitywhen it comes to responding to calls involvingmental illness.

As will be discussed later, some police depart-ments have developed extensive and sophisti-cated approaches to intervening in these situa-tions. In the many jurisdictions that have notdeveloped specialized programs, however, anumber of systemic barriers to effective responsehave been identified. These include having in-sufficient advance warning about specific situa-tions, having inadequate information systems,having inadequate knowledge and skills, lack ofon-the-scene consultation, and lack of supportfrom the acute care mental health system.

Inadequate Advance InformationA common problem is that when a situationarises, police dispatchers often do not ask or passon information about whether the person has amental illness, about whether the situation isdangerous, or about what they might expectupon arriving. Officers in the UK reported thatthe situations were often ambiguous, confusedand lacking context, making it difficult for themto recognize a psychiatric emergency.

Inadequate Information SystemsAnother systemic problem is that police infor-mation systems often do not indicate if a givenperson with mental illness has had previous con-tact with the police. Nor do police systems usu-ally capture how many people with a mental ill-ness come into contact with police. In the eventof a prior police contact, valuable details thatpolice databases often do not capture include:• Information about successful prior inter-

ventions• Information about specific police officers

who had been involved• Indications of whether certain officers had

established a good relationship with theindividuals in question

Lack of Adequate Information andEducation about Mental IllnessResearch shows that police officers’ knowledgeof mental illness is comparable to the generalpopulation, and that training is most effectivewhen carried out in conjunction with a special-ized program for dealing with mental illness. Inthe absence of such a response, when police areprovided with information or training, they of-ten do not have sufficient opportunity to learnthe necessary skills, to practice them, or to up-date them.

The research also indicates that, generallyspeaking, in the absence of education or train-ing, police often have misconceptions aboutmental illness. For example, one study found thatofficers did not understand that:• Confusion and pre-occupation with voices

can affect a person’s abilities to respond todirections

• There is a high risk of suicide for peoplewho have a serious mental illness

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• There is also a high rate of victimizationamong people who have a serious mentalillness

Police require education about how to identifysituations involving mental illness and abouthow to communicate and intervene effectively,so as to minimize the chances of violent or dan-gerous incidents and maximize the chances thatthe person with mental illness accesses the nec-essary care. It appears that the impact of educa-tion and training is greatest in police forces wherethere is a specialized group of officers who dealregularly with situations involving mental illness,and where officers have regular opportunity topractice and update their skills.

Lack of Access toConsultation at the SceneWhen encountering an individual with signsof mental illness, police often lack knowledgeabout how to proceed, for example, abouttheir powers under relevant mental healthlegislation. Research in the UK showed thatwithout access to advice from a mental healthspecialist, police often deferred situations tosenior officers or police physicians. It could beexpected that without access to consultation,situations involving mental illness would bemore likely to be handled less effectively oravoided altogether.

Lack of Responsiveness by theHospital Emergency DepartmentsBoth in the UK and the US, records show thatpolice often experienced long waits in the emer-gency ward after bringing a person to hospital.In the UK, police reported that they were nottreated professionally and that the medical staffdid not always consider or make use of theirknowledge of the individual and the situation.Police in both countries reported that they wereoften told that the persons they brought in didnot meet criteria for admission. When this hap-pened, there was often a lack of other servicealternatives.

Section C: Impacts of theSituation on People withMental IllnessTwo serious issues that have resulted from thecurrent state of affairs are criminalization of per-sons with mental illness and injury or death as aresult of their contact with police.

CriminalizationAs noted, police are often in the position of firstresponders to serious mental health emergencies.Although police intervention accounts for a sig-nificant proportion of referrals into care, esti-mates of the percentage of mentally disorderedoffenders currently in jails and prisons rangefrom 15 to 40%.

In order to prevent criminalization and otherserious incidents, it is important to understandunder what circumstances persons with mentalillness are arrested rather than referred into care,and under what circumstances a person withmental illness receives intervention from neitherpolice nor mental health services.

Likelihood of Arrest Relative toGeneral Population Depends onSeverity of CrimeThe majority of arrests of people with mentalillness are for non-serious crimes that were ei-ther directly or indirectly related to their illness.Common examples include disturbance of thepeace, minor theft, or failure to appear in courtfollowing initial charges. When compared to thegeneral population, however, people with men-tal illness who are suspected of committing acrime are more likely to be arrested. There isevidence to suggest, though, that this differenceholds only for less serious crimes, and that forsome serious crimes, people with mental illnessmay be, in fact, less likely to be arrested thanwould a member of the general population whocommitted a similar crime.

Precipitating Factors of ArrestA study by Rogers indicates that lack of advanceknowledge of mental illness was a contributingfactor to arrests. Within the area under study,most police interventions were initiated by callsfrom the general public, rather than by the po-lice themselves, and that in only a quarter of

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those cases did police know ahead of time thatthey might be dealing with a person with men-tal illness, raising the possibility that the indi-vidual would be arrested rather than referred fortreatment. The possibility of arrest was raised ifthe individual in question had a history of pre-vious arrests, or had an outstanding warrant as aresult of a failure to appear in court for an ear-lier minor offense. Arrest was also more likely ifthere was a violent incident that was precipitatedby the illness.

If there was advance knowledge of illness, ar-rests were more likely if the officer believed thatthe situation could not be resolved informally,if vulnerable persons such as children or elderlywere involved, and if existing mental health ser-vices were difficult to access. Research has docu-mented a number of accessibility issues that makepolice reluctant to go the mental health route:• Having to wait long periods in hospital

emergency wards with a patient• Having patients that were transported and

initially admitted quickly discharged• Having admission denied because the

person had committed a crime• Believing the person would likely be

deemed not to meet committal criteriaPolice officers’ lack of knowledge about com-mittal and treatment also played a role in ar-rests. A UK study showedthat police did not alwaysknow when they were au-thorized to transport a per-son to care under civil in-voluntary treatment legis-lation. A US study showedthat police would arrestbecause of the erroneousbelief that the personwould eventually be re-ferred into care. Anotherfactor that may make arrestmore likely than hospitalization is if the personpossesses multiple problems in addition to theillness, for example substance use, or if the hos-pital staff would deem the person to be danger-ous to the point of being unmanageable in thehospital.

Situations Where No Detention is MadeTeplin & Pruett found that individuals withmental illness who were most likely to be nei-

ther arrested nor hospitalized were individualswho were known to police, and who were:• Seen as too difficult to manage by both the

mental health and criminal justice systems• Or at the other end of the spectrum,

individuals whose behaviour was seen aseccentric, predictable, unobtrusive andnon-offensive.

Injury or Use of Lethal ForceMedia reports of shootings of people who havea mental illness have become increasingly preva-lent. It is important to put these stories into per-spective and to understand that in BC and inCanada as a whole, police rarely use deadly forcewith anyone. A study by Parent, which lookedat municipal police shootings over a 15-year timeperiod between 1980 and 1994, and involvingtens of thousands of police contacts, showed atotal of 15 shootings. During this same period,another 38 situations involving lethal threatswere resolved successfully. However, a dispro-portionate number of these incidents involvedpeople with mental illness.

Of the total 15 shootings, five involved peoplewho had histories with the mental health sys-tem. Of the 15, eight showed signs of mentalillness and at the same time demonstrated sui-cidal behaviour prior to threatening the police

officers. These individualsseemed to meet the criteria fora phenomenon known as ‘sui-cide by cop.’ That is, theyseemed to be in the process ofattempting suicide when thepolice arrived, and/or had triedto induce the officer to killthem. Mohandie and Meloyprovide detailed descriptors ofthe indicators of this phenom-enon. These include many ofthe usual indicators for suicide

but also can include pointing a loaded or un-loaded weapon at police, demanding that thepolice kill them, and shooting at the police.

Parent’s research also looked at general fac-tors that precipitated a shooting. Of the 15 inci-dents, 14 involved a weapon. Eight involved aperson who was holding a gun, and in half ofthese situations, the person fired on the police.In another five incidents, the person was bran-dishing a knife at the police. In one instance,

the percentage ofmentally disorderedoffenders currentlyin jails and prisonsrange from between15 to 40%

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there was a hostage, and in the last incident, theofficer mistakenly perceived that the person hada weapon and was preparing to take aim. Vio-lent crime was also a factor, and in six of the 15incidents, the involved individuals were in theprocess of committing violent crimes. Drugs andalcohol played a large factor in these crimes, andin more than half the violent crimes, the indi-vidual had consumed large amounts of drugs oralcohol.

The overall impact of the situation was se-vere. In addition to the death, and the impacton family members and bystanders, the impacton the police officers involved was considerable.All of the police officers who had killed peopleshowed signs of critical incident stress, and longerterm physical, emotional and psychological dis-tress, even though all ofthem were exonerated.

In the same time period,three police officers werealso killed and a number ofothers were wounded. Inanother 38 incidents in-volving lethal threats, po-lice successfully resolvedthe situations withoutdeadly force. Furthermore,half of the bravery awards to police officers thatwere awarded in that time period went to offic-ers who successfully prevented suicides and de-escalated situations.

Overall, the number of police shootings rela-tive to the total number of interactions with thepublic is very small, and it is important to notethat police in BC have successfully de-escalatedtwice as many incidents involving lethal threatsas they failed to resolve. However, as noted,people who had a mental illness constituted adisproportionate number of individuals whowere shot and killed by police. Despite the factthat in all instances, the individual police offic-ers were exonerated, this situation constitutes aserious problem that must be addressed.

Coroner’s reports have identified systemic is-sues relating to officer training, coordinated sys-tems of response by police and mental health ser-vices, and police protocols around the use of le-thal force. It is clear that police often do not havethe attitudes, skills, information and supports thatthey need in order to be more effective.

Part One: SummaryIn some situations, people with mental illnessare criminalized — most often as a result of rela-tively minor crimes — because of lack of knowl-edge on the part of police officers. This could beeither a failure by police to recognize the pres-ence of mental illness in a given situation, or amisunderstanding of their powers under invol-untary treatment legislation. In other cases, how-ever, police do recognize and intervene in situa-tions where mental illness is in play. In some ofthese cases, the person is successfully transportedto care. In other cases, criminalization occursbecause of a number of factors related to inac-cessibility of hospital services, especially for thosewho don’t meet Mental Health Act criteria, or

are seen as difficult or un-manageable by the mentalhealth system. Individualswho are seen as difficult andunmanageable are morelikely to be left with no in-tervention from both men-tal health and justice systems.

A more drastic conse-quence of the collective fail-ure to respond is the shoot-

ing death or injury of a person with mental ill-ness, a family member, or a police officer. Forthe most part, serious incidents are resolved suc-cessfully. However, individuals with mental ill-ness represent a disproportionate number ofthose who have been involved in such incidents.Shootings take a terrible toll on the individual,the family, the police, and the community. Weneed to look at more effective approaches in or-der to decrease the number of shooting incidentsinvolving individuals who have a mental illness.Part Two of this report looks at some factors thathave contributed to changes for the better, andexamines the improvements that are being madein jurisdictions throughout North America.

media reports ofshootings of peoplewho have a mentalillness have becomeincreasingly prevalent

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police can be moreeffective in deliveringtheir services if theywork with advocatesto try to bring aboutsystemic changes

Part Two: Solutions

Section A: Situationsand Actions thatPrecede ChangeAs police have increasingly interacted with peoplewho have a mental illness, a number of problemshave become apparent. Despite these problems,police have not always modified their practices.Changes to police training and procedures seemto follow from several circumstances. They are:

a) Having an incidentwhere someone dies.This is the most frequentantecedent to change,though this is not in andof itself sufficient forchange to happen. Mostoften, the person withmental illness is the indi-vidual who dies followingpolice intervention. Inother cases, the ill personkills someone else. The death of Edward Yu, aformer medical student with schizophrenia, wasone such example, which led to much media at-tention, public outcry and eventual change.

After such an event, the questions that areasked in the media, in the police and mentalhealth communities, and as a result of inquests,often include:• Did police attempt to defuse the situation or

did their response contribute to its escalation?• Did police receive all the information they

needed to do their job effectively?• Did they seek assistance from family

members, treatment teams, or other indi-viduals important to the person?

• Did police have sufficient training to beeffective?

• Do police and mental health personnel haveappropriate protocols for mental healthemergencies?

Depending upon the answers to these questionsfurther action may follow.

b) An officer taking a personal interest in mak-ing changes. In Canada, Inspector Jamie Gra-ham in BC and Scott Maywood in Ontario are

examples of more senior officers who have takensuch an interest. Tomi Habner (New West-minster, BC) and Rick Parent (Delta, BC) areexamples of patrol officers who have taken ac-tive roles in creating change. In the United States,Sam Cochran from Memphis has been very ac-tive in developing and promoting specializedpolice responses.

c) Having the support and mandate from thepolice infrastructure. In Memphis, the mayorcreated a task force with the authority to createa different model for responding.

d) Implementing a problem-solving and community po-licing model that identifiesthe problem through an ex-amination of police data. Inapplying these models, ad-ministrators work coopera-tively with the mental healthsystem after:• Identifying that a large

number of people withmental illness are using thepolice service.

• Developing a plan to divert people with a men-tal illness out of the criminal justice system.

The questions that follow from this examina-tion can include questions such as the follow-ing: Why is there an increase? What do policeneed to know about mental illness to addressthe concern?

Inherent in this approach, is a longer-termperspective that collects and examines the datawith the intention of using it to inform deci-sions, through collaboration with communitypartners to look for solutions.

Solutions then focus on addressing the an-swers to these questions. With the help of infor-mation systems, police can identify consistentproblem areas, for example, a person who haddelusions about robberies might call a police sta-tion on numerous occasions to report non-exis-tent thefts. Once the pattern has been identi-fied, police would then develop a response jointlywith that person and/or their care providers toenable the police to provide effective assistance.Later on in this report, there will be more dis-cussion about how information systems can playa role in reform.

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Being aware of the factors that lead to orga-nizational changes in police systems can allowproponents to make use of their community re-sources, and to become aware of opportunitiesthat arise to create change. So for instance, itwould be important for advocates and familymembers to identify officers who have an inter-est in better serving people who have a mentalillness, and who are prepared to work towardscreating changes. It would also be useful for themto work with the police to collect data that iden-tifies usage and issues, and that can point topossible solutions. If there is a serious incident,it can become an opportunity to publicize theissues and to promote change. Conversely, po-lice can be more effective in delivering their ser-vices if they work with advocates to try to bringabout systemic changes.

Section B: SpecializedResponses InvolvingPolice and the MentalHealth SystemThere are a number of special programs for in-tervening with those who have a mental illness,developed by police, often in conjunction withmental health crisis response and acute care ser-vices. In some cases, this involves having spe-cialized police units, and in others, it involvesdeveloping a collaborative relationship withmental health programs to provide a tailoredresponse to calls from people who are experi-encing mental health symptoms.

In this section of the report, we’ll outline thevarious response prototypes designed to inter-vene with people with mental illness who comeinto contact with the police. We then will go onto identify key components or functions thateach program addresses.

The range of prototypes includes mobileteams that jointly involve police and mentalhealth systems, either based within the mentalhealth system such as Vancouver’s Car 87 model,or based within the police force, such as the Bir-mingham, Alabama model. It also includes pro-grams that are primarily police-driven, such asthe police ‘reception centre’ model (for example,

Knoxville), and the program that has been mostwidely replicated: the Memphis Crisis Interven-tion Team (CIT) model.

Other approaches exist which have evolvedthat are not specialized approaches, for example,developing joint police/mental health serviceprotocols (a BC example will be reviewed laterin this section) and more piecemeal approachessuch as broad-based police training initiatives,and creating positions such as ‘police liaison of-ficers,’ whose function is to develop partnershipsand coordinated approaches between police,mental health services and other communitypartners (for a full description of these ap-proaches, see Appendix 1.)

Model PrototypesJoint Police/Mental Health Team -Based in Mental Health System

Program DescriptionIn this model, plain-clothes police officers arelocated within a specialized mental health crisisintervention team and respond to calls in anunmarked police car. Incidents are resolved by amental health professional on site, or if neces-sary, the individual can be transported to hospi-tal and admitted, if necessary, under the author-ity given to police under the Mental Health Act.

ConsiderationsThis model, which originated with Vancouver’s‘Car 87,’ is widely seen as a successful exampleof police/mental health system collaboration andhas been replicated in several Canadian centres,including Surrey, Hamilton and Ottawa. Despiteits gaining popularity, a notable limitation of theteam is in its capacity to respond to only onecall at a time and respond only during specifichours.

Joint Police/Mental Health Team -Based in Police Force

Program DescriptionThere are two variations of this model. In theBirmingham, Alabama version, mental healthprofessionals are employed within the policeforce as ‘civilian officers.’ This means they arepolice officers in every respect except the factthey do not carry weapons or have the power tomake arrests. They respond to police calls in-

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volving mental illness that are seen as resolvablewith non-violent crisis intervention techniques.Regular police officers are called in for incidentsconsidered to have the potential for violence.

A second variation of this program was de-veloped in New Orleans, which employs a simi-lar strategy, using trained crisis centre volunteers.

ConsiderationsBoth of these model variations can successfullyresolve a majority of police calls involving men-tal illness, which frees regular police officers forother duties or allows them to leave an incidentsooner.

This model is seen as less feasible in largermetropolitan areas, since this would entail em-ploying or training a large number of mentalhealth specialists at relatively high expense to thepolice.

Reception Centre

Program DescriptionIn Knoxville, Tennessee, all officers are trainedto recognize potential signs of mental illness.Once a case has been recognized, officers thentransport the individual to a reception centrewhere more specialized personnel (also policeofficers) conduct a more thorough assessmentand, if necessary, refer that individual on tomental health services. In instances involvingviolence, a negotiation team intervenes. LosAngeles has a similar model, which involves regu-lar police officers bringing people showing signsof mental illness to an assessment centre. A spe-cialized outreach team intervenes with cases thatinvolve violence.

ConsiderationsThis model’s strength is that it ensures thatpeople with mental illness are transported to careand seen by officers with specialized training inmental health. It also offers greater breadth ofcoverage than the Car 87 model. However, ithas limitations with its capacity to resolve inci-dents on-site, which in many cases may be a lesstraumatic means of intervention.

Specialized PoliceCrisis Intervention Team

Program DescriptionThe prototype of this approach is the Crisis In-tervention Team (CIT) in Memphis, Tennessee.CIT has been widely replicated and consequentlymuch more information is known about thedetails of the approach compared to other pro-totypes. In this model, officers with specializedtraining work within each catchment area of thepolice force, performing mental health crisis in-tervention along with their other duties. Offic-ers volunteer for the teams, and then are selectedon the basis of personal characteristics such asempathy and communication skills. After beingselected, they undergo intensive training in ar-eas such as non-violent crisis intervention, pro-tocols for responding, and information aboutthe experience of mental illness.

When an intervention is made, the incidentis either resolved on-site, the individual is trans-ported to a medical centre for treatment, or isreferred to other forms of mental health care.

ConsiderationsOutcome data suggests that this model has re-sulted in successful resolution of a high propor-tion of incidents and in considerable satisfac-tion by mental health consumers and families.The model also is able to respond to the highestproportion of calls, compared to other models.The success of the model has been attributed tovarious factors, including the careful selectionof officers and the nature of the training – spe-cifically, its comprehensiveness and the oppor-tunities it offers team members to practice and‘put into play’ the skills and knowledge impartedthrough the training on a daily basis. The closecollaboration the program has achieved withmental health services is a third factor in its suc-cess. The force has an agreement with the medi-cal centre around a ‘no-reject’ policy, meaningthat when officers transport an individual fortreatment, they are unlikely to wait more than15 minutes and the individual will be providedwith services.

One drawback of this model is that comparedto the mobile team approach, incidents are lesslikely to be resolved on-site, and the individualis more likely to be transported to hospital. Theprogram’s founders stress that in order for theapproach to work, the mental health system it-

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Section C:Program ComponentsContributing to SuccessThe model most widely studied and replicatedis the Crisis Intervention Team (CIT), developedin Memphis, Tennessee. Based on their experi-ence in transferring the CIT model to other ju-risdictions, Dupont & Cochran identified anumber of components of effective programs:1. Careful selection of a core group of specialized

officers, who can hone their skills, and be thefirst responders in situations involving peoplewho have a mental illness. Dupont & Cochrannote that not all officers are suited for workwith people who are in distress and, there-fore, should be screened for their suitabilityto work with people who are in need of crisisintervention skills.

2. Providing specialized and ongoing crisis inter-vention skills training to the core group, the CITmembers. The training is aimed at developingthe skills for officers to carry out a staged in-tervention continuum, making use of non-violent crisis intervention skills as a key ele-ment. Dupont & Cochran strongly advocateagainst one-time training sessions that lackexperiential components and they questionthe likelihood that limited exposure to con-tent and skills will significantly impact per-formance.

3. Having a specialized system of dispatch includ-ing training for dispatchers

4. Having good information systems in place.When police look at who they are serving, asmuch as 40% of police work involves peoplein crisis or people experiencing a mental ill-ness. However, this is often not apparent be-cause there are usually no systems for track-ing this information.

5. Having an accessible point of entry where cov-erage is available throughout the week, andthroughout the geographical area in question.

6. Developing protocols for achieving close collabo-ration with mental health services, and for ad-dressing the barriers to mental health care,including no-reject policies that improve ac-cess to hospital and other mental health ser-vices, and access to services for co-occurringmental illness and substance use problems.

self must make a commitment to providing cri-sis and acute care services, and to other forms ofcommunity mental health services, since the CITteam relies on both for support and referral.Police and mental health services must also makea strong commitment to collaborate and developmeans of resolving disputes that may arise.

Joint ProtocolsMost other programs tend to focus more on thepolice and the mental health services and tendto attempt to reform responses within these ser-vice systems. Dawson Creek, a small commu-nity in northern BC, has developed a compre-hensive integrated model of responding to peoplewith a mental illness. In that community, whenthere is a concern in the community about aperson, community members usually call theRCMP. Because it is a small community, theRCMP sometimes know the individual, and areaware of whether the person uses the mentalhealth system.

As a result, when the police are the first con-tact for a person known or suspected to have amental health problem, they contact the mentalhealth centre directly. If there is a concern aboutviolence, the RCMP rather than the mentalhealth team will take the person to hospital wherethey inform the attending physician of previousmental health contact, if known. If there is not aconcern for violence, the mental health team willassume primary responsibility. Either way, theemergency ward physician consults with themental health centre (a separate agency from thehospital) and determines if the person has beenseen previously. The mental health centre staffthen provides an assessment if the individual wasnot previously known, and consultation if theperson is known.

The first contact may, however, be throughan outreach mental health team that assesses thesituation, talks to the family, and involves theRCMP if needed. In the event that a person whohas been arrested and jailed is suspected of hav-ing a mental illness, if officers feel they need anassessment or consultation at the jail, a forensicnurse will provide assessments for the officers.Once a month the relevant players meet to dis-cuss issues related to those who have a mentalillness and are involved with the criminal justicesystem. See Appendix 2 for more informationon joint protocols such as this.

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ognize and interact with people in distress, andon knowing how to react in a way that ensuressafety for all concerned. See Appendix 3 for moreinformation about staged interventioncontinuums. The most effective training pro-grams often use mental health consumers, fam-ily members, mental health service providers, andpolice officers to provide the training. In the CIT,regular patrol officers are trained to provide sup-porting roles such as crowd control, informa-tion-gathering and back up support. Dispatch-ers also receive special training in recognizingand responding to a mental health call.

Most of the models reviewed involve collabo-ration between police and mental health serviceproviders. Because of this, many training cur-ricula include the opportunity for cross train-ing, that is for members of each agency to makeeach other aware of the nature of their jobs, andtrain the other on skills they may need to em-ploy (e.g. mental health professionals providingtraining about communicating with someonewith a mental illness; police officers trainingmental health staff in crisis intervention for situ-ations involving firearms or violence).

What seems to be common to all of the pro-grams reviewed is a mechanism for staff to learnhow to interact effectively with people who showpsychiatric symptoms. Police training generallyalso includes topics such as the goals and out-comes of treatment, psychotropic medications,crisis intervention and de-escalation, dispositionoptions, confidentiality, and making appropri-ate referrals to the mental health system. Severalalso include training in the use of non-lethalweapons. Training for the most effective pro-grams always includes practice, field supervisionafter training and continuous opportunities forskills upgrading.

One aspect of training that appears to be quiteeffective but is not a component of many of theprograms is experiential education that comesabout through the opportunity to meet mentalhealth consumers and their families. One com-ponent of that experience is exposure to the per-spectives and experiences of those who are liv-ing with mental illness. Another component ofthis type of training is to learn about consum-ers’ and families’ previous experiences with thepolice, and to learn about what works and whatdoes not work from that perspective. The thirdcomponent is the opportunity for police to meet

7. Development of dispute resolution mechanismsto resolve issues as they arise.

8. Measuring outcomes, and disseminating the re-sults, in order to ensure that the broader or-ganizational structures respond.

Each of these issues will be described in greaterdetail below where possible, with reference tothe CIT model, and to the various other pro-gram models that have been reviewed. The lastissue, measuring outcomes, will be described inAppendix 1 to the full report. This contains adetailed review of literature that is the basis ofmuch of what has been discussed in the report.The review itself, however, goes beyond the scopeof the present report.

SelectionIn the CIT program, officers volunteer for theteams, but not all officers are accepted. Duringthe screening process, their records are reviewedto determine that they demonstrate good judg-ment and maturity. They take a skill test to de-termine their strengths and weaknesses, and theyare required to participate in a structured inter-view. The program looks for officers who dem-onstrate enthusiasm and excitement for the workand they select officers who demonstrate flex-ibility, empathy, calmness, creativity, intuitive-ness, and a willingness to try new techniques.

Car 87 in Vancouver selects officers andnurses with dispositions that would make themsuitable for this work. Officers, for example, arechosen for their willingness to work in this set-ting, and their interest in assisting people withspecial needs. They volunteer for the programand often have undergraduate degrees in thebehavioural sciences. Team members do not re-ceive special training once selected.

Both of the programs described above havecomprehensive screening criteria that select par-ticipants with particular skills and abilities suchas independence, flexibility, creativity, empathy,and the ability to think on one’s feet.

TrainingGenerally, specialist programs provide additionaltraining to officers with an emphasis on a stagedcrisis intervention continuum, ranging fromminimal intervention, through to non-violentcrisis intervention, and as a last resort to the useof non-lethal and lethal use of force. The inter-vention continuum is based on the ability to rec-

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people who have a mental illness who are well,and who can talk about what it is like to be ill.

Two programs that do this are the Schizo-phrenia Society Partnership program, which hasmental health professionals, consumers, andfamily members jointly present to police in train-ing. The other is the Queen Street Outreach Pro-gram in Toronto, which provides police officersthe opportunity to learn the consumer perspec-tive. The Queen Street Program touches on thefollowing topics:• Socio-economic factors that lead to poor

functioning and mental health• Medications and side-effects• Traditional and alternative treatments• Myths and truths (e.g. incidence of vio-

lence, coping and recovery)• Stigma and discrimination• The experience of mental illness and its

impacts• Helping strategies (e.g. client-centered

interventions)• Legal issues (restrictions and rights and

their impacts)Both police and consumer perceptions of thisprogram are that attitude, knowledge, sensitiv-ity, and response to people with a mental illnesshave improved. Since the training began inToronto, there have been no further deaths ofpeople who have a mental illness as a result ofinteractions with police, even though the num-ber of calls has increased.

Dispatch and ReferralAs noted, the CIT model has a specialized dis-patch function, involving trained dispatchers.Despite Dupont & Cochran’s recommendations,most services do not appear to have special dis-patch and referral mechanisms for people in dis-tress. There were two exceptions noted in thisreview. For the Car 87 program in Vancouver,referral involves a 3-step process: intake, assess-ment and resolution. Intake involves collectingdetailed information in order to determine ur-gency and risk. When a call is deemed to be ap-propriate, the team will go to the person’s resi-dence and talk to them as well as to other rel-evant people who are on the scene. The on-callpsychiatrist may provide telephone consultation,review medications, or attend in person. Teammembers carry small amounts of medication thatcan be administered on site if needed.

The CIT program itself provides special train-ing for their dispatchers, to enable them to better• identify if the call involves a person who

has a mental illness• collect relevant information about the

personProviding triage would seem to be an importantelement of an effective program particularly in alarge population centre with a high volume ofcalls involving people with a mental illness. Thiswould allow for less intrusive services to be usedwhen appropriate. At the same time, having amechanism to collect relevant information be-forehand would likely result in a more effectiveresponse at the scene. As we learned earlier, po-lice often reported that the situation was oftenambiguous. Furthermore, they often did notknow before their arrival that the person whowas the subject of a call had a mental illness.Having good information could potentially im-prove the response and prevent escalation.

Access to Information and FeedbackHaving information systems that provide infor-mation on mental illness and whether it is in-volved in a given situation enables police to in-tervene more effectively. This provides them withopportunities to consult with knowledgeablemental health professionals, and to assess or ruleout any risks, thereby helping to reduce the un-certainty that frequently accompanies their calls.It also helps police to take preventative actionby identifying high use locations and individu-als, and taking appropriate action. However,appropriate precautions need to be taken in or-der to address privacy concerns, and to ensurethat mental health records are not misused.

The following are examples of strategies takenby various programs to address their informa-tional needs, while at the same time respectingethical and legal issues having to do with confi-dentiality and privacy of information.

The Albuquerque, New Mexico, CIT teamassigns detectives who do intensive follow-upafter any intervention is made, providing infor-mation that can be used to make a more effec-tive response in the future. The detectives visitpeople who are likely to pose a threat, identifyresource-intensive individuals and take measuresto reduce the number of police contacts. Theyalso provide bulletins to police about potentiallydangerous individuals.

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As mentioned, most other teams did not pro-vide full coverage, but they did develop ways ofproviding expanded coverage. In Knoxville, Ten-nessee, one evaluation unit serves the entire city.The team provides full coverage during the day,evening and night, and team leaders provideweekend coverage. In Birmingham, Alabama, theunit members are on duty 7 days a week for 15hours per day and on-call the rest of the time. InVancouver, daytime coverage is not available andregular police officers or the mental health emer-gency team responds to calls. A single team cov-ers each of these cities at any one time. The draw-back of this is that if they are already answeringa call, they are not available for other calls thatcome in. In Vancouver, if the unit cannot re-spond immediately to other patrol officers, theywill provide advice to assist officers to manageand/or intervene in the meantime.

Access to Mental Health ServicesAs discussed earlier in this report, one stumblingblock to police intervention is that mental healthservices have not been accessible to people withmental illness who are encountered by policeofficers in the course of duty. Ideally, police andmental health systems would develop a no-re-ject policy, meaning that if a police officer neededsupport from the mental health system – for in-stance, if he or she felt there was a need for ahospital bed – then there would be some guar-antee that the services would be available. Par-ticularly when people have concurrent disordersand other serious and complex needs, the no-reject or no-refusal feature is identified in theliterature as a characteristic of an effective plan.Having access to a specific program for dealingwith concurrent disorders, notably mental ill-ness and addictions, is also seen as a characteris-tic of an effective program.

Having these options makes it more likely thatpolice will divert people out of the criminal jus-tice system and into the mental health systemwhen they perceive that a person is at risk.

A range of strategies has been developed todeal with this issue. In some cities, police pro-grams have preferred status in hospital emergen-cies. One defining characteristic of the CIT pro-gram is that if a person requires hospitalization,officers can leave consumers at the hospitalwithin 15 minutes of arriving, as set out inMemoranda of Agreement that exist between the

In Los Angeles, the police members of themobile outreach units have access to mentalhealth records of referrals; in turn, the mentalhealth professionals have access to police recordson arrests, warrants, prior contacts and weaponownership. Unit members may not share infor-mation from the other’s records with colleaguesof their respective organizations who are notmembers of the unit.

In Madison, Wisconsin, the police receive feed-back in writing on all referrals that they make tothe mental health system, and when an individualwith mental illness is identified by the police ashaving many encounters with police officers, po-lice are able to request a review of the person’streatment plan by the mental health system.

In Lexington, Kentucky, police collect infor-mation about mental-health-related calls, allow-ing them to identify trends or hotspots in needof response. For instance, they have identifiedindividuals and locations in 3 boarding homesthat were generating a substantial number ofcalls. As a result, they were able to do some prob-lem-solving to better develop responses to peoplewho had a mental illness and who were in fre-quent contact with police, and were able to workjointly with families, service providers, and in-dividuals in the source locations to develop amore effective response at those sites. They didthis by creating unique police interventions andprotocols that were tailored to better meet theneeds of the individuals, to address the specificrequirements of the locations, and to take intoconsideration the circumstances that lead to theproblems.

Accessible CoverageSpecialized programs varied in how much cov-erage they provided – that is, when coverage wasavailable, and how wide an area they could serve.Ideally, a specialized crisis response should beavailable 24 hours a day, seven days a week to allareas in a given town or city. Some programsreviewed had such coverage, but most did not.The CIT provided full coverage to people whowere experiencing psychiatric crises. In the CIT,the officers are based in teams within police di-visions that serve specific geographic areas withinthe city. Officers engage in regular patrol dutiesin addition to their CIT functions, and are calledupon to respond to all mental health incidentsin their area.

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Memphis police and the University of Tennes-see Medical Center. There is a no-refusal policyin place at the medical centre, so that if officershave assessed and diffused a situation and de-cide that the individual is in need of treatment,the Center accepts responsibility for ensuringthat the person’s needs are met. The medical cen-tre also has an agreement with the state hospitalnot to refuse any patient that meets minimumcommitment criteria.

In Pennsylvania, police use a free-standingpsychiatric hospital that provides crisis interven-tion, telephone hotline assistance, crisis mobileoutreach, and referral to treatment. In addition,it operates a detoxification and dual diagnosistreatment program. When police identify some-one who may have a mental illness, they eithertransport the person to the centre or the centresends an ambulance to meet police. The ambu-lance personnel have medical and psychiatrictraining and provide specialized treatment.When an ambulance is sent, police do not needto go to hospital, but rather provide a statementto the ambulance personnel that is used to in-form decisions for commitment.

Mechanisms for Collaboration andDispute Resolution Between Policeand Mental Health ServicesInherent in all collaborations between agenciesare inevitable challenges. Sometimes, policies ofeither agency can interfere with effective inter-ventions. Sometimes, there are differences in theinterpretation of protocols that have been devel-oped to guide collaboration. Sometimes, attitudesprevent effective collaboration. Different pro-grams have developed ways to address these.

In Los Angeles, both the unit that assessespeople for symptoms of mental illness and theoutreach team that intervenes when there is po-tential for violence have 24-hour access to high-level administrators to resolve any disagreementsthat arise. In Madison, Wisconsin, a police liai-son officer position was created within the po-lice force who was responsible for• developing policy about mental health issues• assisting officers on the scene• resolving police/social service issues• reviewing all police contacts with people who

have a mental illness to ensure that policeunderstand and respond appropriately

As noted earlier in the report, collaboration be-

tween police, mental health professionals, andthe mental health advocacy community is nec-essary for service change to take place in the firstplace. As suggested above, mechanisms are nec-essary to ensure that such collaboration is main-tained over time, to ensure that an effective sys-tem of response continues to take place.

Various other means for promoting collabo-ration have been developed, either in specializedprograms, or in areas where collaboration hasbeen achieved on a more informal basis. A de-scription of these is provided in Appendix 2.

The issue of collaboration brings this reportfull circle, for collaboration between all key stake-holders – police, mental health services, mentalhealth advocacy groups, and local politicians –is a necessary ingredient for any meaningfulchange to occur towards the implementation ofa coherent, concerted approach to improvingoutcomes for all concerned, when people withmental illness come into contact with the po-lice. Once these initial partnerships are in place,then leadership from individuals in any or all ofthese sectors is crucial to getting the change tohappen.

Measuring OutcomesAs mentioned at the outset of this section, thefinal attribute of a successful program, once ithas been established, is to be able to measureand communicate the results that have beenachieved and to make any changes that are nec-essary. In Appendix 1, we present a review of theresearch that has been carried out to date, andwhich has identified many of the attributes ofsuccess that have been identified.

While progress has been made to date inachieving success and in measuring and dissemi-nating these results, more work has to be done,particularly in confirming that these interven-tions achieve the outcomes that matter most:improving the lives of people with mental ill-ness in a way that is safe for all parties concerned.

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Part Three: Conclusionsand RecommendationsThe experience of first treatment for manypeople with a mental illness starts with beingarrested or brought into care by police, an expe-rience that is usually traumatizing for those in-dividuals. Consumers need the benefit of pro-grams that help them to understand their treat-ment needs and to recognize escalating symp-toms so they can avoid the need for police con-tact. If they cannot avoid police contact, thenpolice and emergency personnel need to learnhow to interact effectively with them and tomake the experience less traumatizing.

One of the greatest challenges in conductingthis review is that very little has been writtenfrom the Canadian perspective, based on Cana-dian experiences. Most of the research and ex-perience is American. Yet, even in the UnitedStates, there are few researchers. Most policeforces do not even keep statistics on contacts withpeople who have a mental illness and informa-tion about outcomes is more sparse, even whenthere is a special program.

Still, it is possible to draw some conclusionsfrom the information that exists. Police deal withpeople who are very ill and who are often expe-riencing psychiatric emergencies. Police do notoften have sufficient information to know aheadof time that a person who is ill is at the scene,and the context is often very ambiguous. Someincidents involve individuals with multiple prob-lems, and a small number of these are poten-tially violent. It is clear that police officers wantto be of assistance to people who are experienc-ing psychiatric symptoms. However, they needto have the skills and supports from the policeand mental health systems to help them to rec-ognize people who have a mental illness, and tointeract effectively with them. The consequencesof not doing so can be extremely serious, includ-ing injury and death.

It is clear from this review that providing po-lice with experience and training does not neces-sarily address the needs of people with mentalillness. It appears to be very difficult to changeattitudes and behaviour if officers do not alreadyhave some pre-requisite skills and characteristics.It is difficult for training to have an impact if of-ficers do not have the opportunity to implementand upgrade those skills on an ongoing basis.

There are a number of policing models thatdivert people with mental illness from the crimi-nal justice system. The most effective programsinvolve the police and the mental health systemsas well as consumers and family members. Inthe most successful programs, police officers areselected on the basis of attitudes and skills thatdemonstrate suitability for the work. The policeand mental health professionals provide train-ing to each other, share relevant information, andprovide mechanisms for resolving disputes andbreaking down systemic barriers. Training isongoing. Furthermore, police officers maintainconsistent relationships with the people theyserve, and police information systems providemechanisms for officers to gain access to infor-mation about previous contacts and successfulinterventions. Disseminating information andassessing quality services are also important com-ponents. Having access to a no-refusal site en-ables this kind of service to gain acceptance bypolice in assisting consumers to access the ser-vices that they need.

Cities clearly require formal protocols andprocedures to deal with the larger, more com-plex service delivery systems. In smaller com-munities, it is often easier to achieve this level ofcooperation informally, if the community is largeenough to sustain basic services such as an after-hours service and a hospital with psychiatriccoverage.

When the community is too small to sup-port basic services, it either has to rely on largercentres for back up or it has to partner with otherneighbouring villages in order to be effective. Insmaller centres, particularly in remote areas,people with psychiatric disorders often wait inpolice cells until they can be transported to hos-pital. Clearly, this is unsatisfactory, and thesesmaller communities may have to look at theother alternatives. These can include providingsecure space in hospitals or clinics, designatingspecial police cells for people who have a mentalillness and changing their design, accessing re-mote training, providing police and medicalpersonnel with a broader range of assessment andtreatment skills, and accessing psychiatric con-sultation at a distance.

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Unfortunately, despite the fact that there arenumerous special police programs, it is unclearwhether they contribute to better clinical out-comes for consumers. They clearly assist policein diverting those with a mental illness out ofthe criminal justice system, but we do not knowwhether they lead to improved quality of life forconsumers. It is even more critical that we avoidsituations where people are injured or killed be-cause they were unable to access mental healthservices and the first responders did not how tode-escalate the situation. Whatever services orsolutions are developed must also avoid creat-ing a system where police, families, and mentalhealth professionals collaborate to get people intothe criminal justice system in order to get theminto treatment.

RecommendationsBC should develop a comprehensive strategy foraddressing the needs of people with a mentalillness who come in contact with the police. Thisstrategy needs to include special police units thatincorporate the critical components of effectiveprograms. At a minimum they should• collaborate with the consumers, families,

and the mental health, addictions, andsocial service systems in the design andimplementation phase

• screen and provide ongoing training andsupport to specially-trained officers

• ensure that dispatchers and regular officersare trained to support these units

• within appropriate legal and ethical frame-works, collect information and provideofficers with access to key records aboutpolice contacts with people who havemental illness

• develop protocols for police and mentalhealth system collaboration, and mecha-nisms for resolving disputes as they arise

• evaluate their impact on the people they areserving

This strategy needs to be based on a collabora-tive approach between police, mental health ser-vices, and the mental health advocacy commu-nity. It must also be flexible enough to meet theunique needs of remote and rural communities,as well as urban centres, recognizing the diverseethnocultural and geographic needs of each.

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Appendix 1: OutcomesProgram Satisfaction and Outcome DataThis last section will look only at outcomes forspecialized programs involving the police. Po-lice do not generally collect information aboutpeople who have a mental illness unless they havespecial programs. These programs have identi-fied that people with a serious mental illness fre-quently call the police and use a substantial pro-portion of police resources. Researchers foundthat 47% to 80% of police officers rated theirprograms as effective in meeting the needs ofpeople in crisis when they had a special program.This was considerably better than the experiencesof police departments without specialized pro-grams.

It is interesting to note, however, that whilemost officers felt confident about their own abil-ity to manage calls from people experiencingpsychiatric crises, they were less confident abouttheir colleagues’ abilities. Since it is common formost people to rate themselves as better thantheir peers, one way to try to confirm that pro-grams are working – beyond self-reports – is tolook at outcomes.

Unfortunately, most specialized police pro-grams have not been evaluated and their perfor-mance has not been compared to regular policeforces. The CIT program has collected infor-mation and examined impacts in the most de-tail. Besides the CIT reports, only one otherpublished study looked at outcomes for the re-cipients. One other study examined whethermore diversions happen when there is a specialprogram and the last study looked at whetherno-refusal sites were effective in assisting police.

Impact on Quality of LifeLos Angeles, California, conducted the onlypublished research study that looked at outcomesof its program for consumers. They did a six-month follow-up of those who had received theirservice. The people who received services werethose who had a high incidence of psychiatricsymptoms, committed serious violence againstothers, showed poor compliance with medica-tion, and demonstrated serious substance useproblems. At follow-up, only 11% were home-less compared to 31% at initial referral; 39%were in outpatient mental health treatment, 12%

were in locked mental health facilities, and 15%had been assigned to guardians.

This data suggests some success for the pro-gram in connecting people to mental health ser-vices. Earlier studies showed that many peoplewho have a mental illness and who come in con-tact with police are not involved in any services.Still, the authors of this study found that 24%were arrested at a later date, and 12% of the to-tal were arrested for violent crimes. A further42% were re-hospitalized. While this data sug-gests that the program was able to divert mostof the referrals away from the criminal justicesystem, it is clear that these were individuals withmany challenges. Clearly, their problems werenot resolved simply by being diverted into themental health system and away from the crimi-nal justice system.

The CIT program has reported the follow-ing improved client outcomes as a result of in-tervention:• Police used restraints and deadly force less

often• Fewer consumers were sent to jail• Ongoing and more positive relationships

developed between police and those whohave a mental illness

• Reduced stigma and perception of dangerattached to mental illness

• Involuntary commitments have decreasedfrom 40 to 25%

• Consumers have demonstrated 15% fewercriminal offences a year after intervention

• Access to care was provided for those whohave been least served by the mental healthsystem, that is, 45% of the people who werebrought in by police have never had mentalhealth treatment

• quick response times for 92 to 97% ofcases; response occurred within 10 minutes

In a personal communication, S. Cochran indi-cated that following CIT implementation:• When police bring people to hospital, the

consumers are much less agitated and aremuch more receptive to treatment thanpreviously

• Family members and consumers call thepolice to ask for assistance whereas in thepast family members were critical of thedepartment and fearful for their ill relatives

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• Consumers did not call the department atall previously, and they now call for assis-tance in addition to reporting when theyare victims of crime

Looking at the results from these together, twoclear benefits to people who have a mental ill-ness are reduced homelessness and improvedaccess to treatment and other mental health ser-vices. The CIT also appears to provide less coer-cive and less intrusive treatment to the people itserves, compared to what was provided in thepast. The Los Angeles program also providesincreased access but it appears to provide a morecoercive service. This may be because that de-partment is dealing with a group of people whohave more serious and complex problems thanthe Memphis group, or this may be a functionof a specialized program that is not as individu-alized as the Memphis program. Further researchwould have to be conducted to determinewhether the group of people served by the CIThas comparable levels of illness and needs as thepeople in Los Angeles study.

Benefits for PoliceResearch on the CIT has also found the follow-ing benefits for the police:• A decreased need for more intensive and

costly police responses (e.g. high intensityspecialized police units such as SWAT)

• Police, those with mental illness, and othersexperienced fewer injuries

• Improved police morale• Police spent less time in ER• Officer downtime is signifi-

cantly reduced for crisis events• Officer recognition by the

community has increased• Implementation of CIT in-

volves minimal costs

Benefits for theMental Health SystemThe CIT program found the follow-ing benefits for the mental healthsystem• Police report better informed

health care professionals inhospital emergency rooms

• Less violence occurred in themedical centre

Do Specialized Police ProgramsDivert People out of theCriminal Justice System?The research project described below comparedthree specialized programs to determine if theywere effective at diverting people from the crimi-nal justice system prior to arrest. It comparesdiversion for three models that were describedearlier in this paper. The three programs were inMemphis (specialized police teams: CIT), Bir-mingham (mobile police-based civilian team),and Knoxville (evaluation unit).

To review, the specialized police teams con-sist of teams of police officers in each divisionof a police service who have received special train-ing to enable them to assist with and, if neces-sary, defuse situations involving people who areshowing psychiatric symptoms. The police-basedmental health team consists of a single mobileteam of trained mental health professionals whoare based in a police force and respond to callsfrom patrol officers. The evaluation unit con-sists of a single specially-trained unit that pro-vides assessments and assistance for people withpsychiatric symptoms who are brought in bypatrol officers.

As indicated in Table 1 below, depending onthe program, between 5 and 13% of people werearrested, and the programs responded to a rela-tively high number of the total calls to the men-tal health system (ranging from 28% in Birming-ham, 40% in Knoxville, to 95% in Memphis.)While there was a difference in the proportion

MODELSpecializedPolice Team(CIT)

MobilePolice BasedCivilian Unit

EvaluationUnit

Proportion ofmental healthcalls directedto the team

95% 28% 40%

Resolution onsite

23% 64% 17%

Taken totreatment

75% 20% 42%

Response Time Shortest Longest Middle

Arrests 6% 13% 5%

Table 1:Comparison of three police forces on their abilityto divert people into the mental health system

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of calls to which each of these teams responded,when they did respond, most individuals werediverted out of the criminal justice system.

In terms of responsiveness, both of the pro-grams that provided lower response rates had asingle team. The civilian-based team is only fullyoperational for 14 hours per day and limitedhours on the weekend, while the evaluation teamis available 24 hours. The CIT model, featuringmultiple teams available 24 hours a day has aclear advantage in that it allows more individu-als to receive a specialized response.

Knoxville’s evaluation unit provides a mid-range response, providing coverage for as manyhours as the Memphis team, but with propor-tionately fewer specially-trained officers at anygiven time. Therefore, it is limited in its capac-ity to provide service to as many people as mul-tiple teams, and it is unable to respond to morethan one situation at a time.

The Birmingham model of having a singlemobile team during limited hours appears toprovide the lowest rate of response because ofthe challenges inherent in travelling over largegeographic areas, and the capacity limitationsinherent in a single team. When the police-basedcivilian unit was compared to the other teamson response times, they were found to be sig-nificantly longer than for the other two modelsas well. As a result, police in the city often madedecisions and took action without using theteam. In other words, having a single unit in anurban area means that it was not available for allcalls in all locations.

The strength of the mobile, police-based ci-vilian mental health team appears to be its abil-ity to resolve calls on-site. Compared to the otherprograms, it was able to resolve the highest num-ber (64%) on-site, a significantly higher propor-tion than both the other models, which wereeach able to resolve approximately 20% of calls.As might be expected, having the highest pro-portion of resolved cases is associated with hav-ing the lowest rate of taking people to treatment(20%), compared to the other models: Knox-ville evaluation unit (42%), and Memphis CITteam (75%). This may be an indication of theeffectiveness of having trained mental healthprofessionals (as in Birmingham) who are:• better able to diffuse situations• more able to assists clients to

develop a plan of action

To some extent, this is confirmed when examin-ing the same statistics for the specialized policeteam. They were most likely to transport peopleto mental health treatment and least likely toresolve the situation on the spot.

It is also interesting to note that the mobile,police-based mental health unit had the highestrate of arrests, although it was still much lower(13%) than rates in forces without special pro-grams. The specially-trained police teams hadeven lower rates of arrest at 6% and 5%. Con-sistent with the earlier research, this may reflectreluctance by the police to arrest individuals withmental illness when they have reliable alterna-tives for referral (the Memphis model had themedical centre as a reliable backup; the Knox-ville model had the assessment centre as abackup).

Regardless of which of the three models wasused, diversion from the criminal justice systemwas much higher than was reported in earlierstudies that examined non-specialized teams:92% diverted vs. 79% diverted. The authorsconcluded that all three programs were effectivein diverting people with a mental illness fromthe criminal justice system, and that the no-re-fusal site for police referrals was a significant fac-tor in achieving success.

In a second study, several of the same research-ers looked specifically at the issue of the no-re-fusal site, comparing the CIT site in Memphis,and two additional sites that had no-refusal poli-cies. One of these other two was also a CIT pro-gram, but outside of Memphis.

The authors concluded that a no-refusal sitewas an effective mechanism for assisting those witha mental illness and returning police officersquickly to their beats. The factors that theydeemed to be important included the following:• All three programs were available 24 hours

per day, and had co-located mental health/substance abuse programs

• All three offered cross-training that enhancedcooperation and mutual understandingbetween police and mental health, and wereclosely linked to community services

• They offered police a streamlined intakeprocess

• Their procedures recognized the dual rolesof public safety and individual heath care,and provide a legal foundation to supporttheir models

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They concluded that collaboration between po-lice, mental health services, and advocates was amajor factor in the effectiveness of these programs.

SummaryIt is clear that specialized police programs re-duce the use of the criminal justice system bypeople with a mental illness, and that they aremore effective at doing so than programs with-out special teams. At the same time, the au-thors identified some important considerations.These would need to be addressed in the de-velopment and implementation of new pro-grams. For example, where there is a singlemobile team in an urban area, availability be-comes a concern. The team members may beable to address access issues by providing con-sultation by phone when they are not availableto respond, as in Vancouver. Another consid-eration in the choice of model would be thesize of the catchment area. The single mobileteam tends to work well in smaller cities, mul-tiple teams work better in larger centres.

Unfortunately, information about quality oflife or outcomes for participants is limited. Cur-rently, the GAINS Center, a research institutein Florida, is looking at outcomes for a numberof different programs. However, the data is notyet available. Clearly, this kind of informationis critical in making decisions about the effec-tiveness of the different models. Diversion is im-

portant, but only if it contributes to more effec-tive treatment or a better quality of life. Furtherresearch needs to examine the clinical and psy-chosocial outcomes for individuals in the dif-ferent diversion programs. The CIT program hasexamined this in the most detail, and has dem-onstrated some positive findings such as fewerrepeat offences one year after intervention andbetter relationships with police. The Los Ange-les study also found some positive results.

Still, we know that contact with police is of-ten traumatic for people with a mental illnessand none of the studies looked directly at levelof trauma and fear of police. Only two pro-grams looked at whether consumers were betteroff following contact, and this needs to beexplored further. In conducting interviews withrespondents, most felt that their work benefitsthose with a mental illness. However, one wouldexpect that people would be involved inprograms that they supported, and that theirimpressions might be biased. Having data toconfirm these perceptions would be helpful. AsNancy Pangabko, a crisis consultant suggested,one of the primary goals should be to serveconsumers’ needs when they are in crisis. It istempting, however, to design a system thatserves the needs of the criminal justice systemwithout improving life for those with a mentalillness. It is important to promote a person-oriented approach.

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Appendix 2: Other Non-Specialized Approaches toAchieving Collaborationbetween Police andMental Health SystemsLiaison OfficersThe City of London in the UK and the City ofToronto have liaison officers. In Toronto, therole of this person is to• liaise with community agencies on task forces

that look at issues such as legislation andhomelessness

• develop inter-agency responses, tools, andprograms to assist people with mental illness

• educate other agencies about police/mentalhealth issues

• review information about contacts betweenpolice and people with a mental illness

Protocol DevelopmentAt a minimum, a number of police forces in theUnited States and in Canada have worked withmental health departments to develop protocolsfor responding. These protocols vary considerablyin the amount of detail that is provided.However, they appear to be the least effectivemechanism for developing sound programs.Most do not appear to require officers to haveany special training, seemingly assuming thatofficers have the skill and knowledge toimplement. The protocols that were examinedfor this study did not provide any mechanismsfor resolving disputes or for addressing concernsand there was no information available toevaluate whether these protocols were beingfollowed or whether they were effective.

Appendix 3: StagedIntervention ContinuumAs described below, many of the programs re-viewed provided officers with a continuum ofresponding or alternative disposition options.

One feature of the CIT program is that offic-ers regularly visit with mental health consumersand establish ongoing relationships. As a conse-quence, consumers will call their designated of-ficer to ask for assistance. However, there aretimes when another person makes the call. If dis-patchers classify a call as a mental disturbance,it is assigned to a CIT officer. In Memphis, theCIT lapel pin identifies the CIT officer and sig-nifies that he or she becomes the officer in chargewhen they arrive at the scene. Once at the site,the CIT officer will assess the situation. Becausethe team has established excellent relationshipswith other mental health services, they will re-lease clients into the care of their case managers,if appropriate. They will also transport individu-als to hospital if required.

When they arrive, they use a multi-stage con-tinuum of intervention. Their first levels of in-tervention involve effective communication andnegotiation. If negotiation and de-escalation fail,they bring out a non-lethal weapon (a long-rangerifle that fires rubber batons). The organization’sexperience is that this weapon is preventative inthat it is quite intimidating in appearance. Of-ten, the act of bringing it out is often sufficientto convince someone to change his or herbehaviour. If not, they will use it, and if this isunsuccessful, their continuum includes lethalforce as the final alternative.

In Knoxville, all officers are trained to iden-tify people who have a mental illness. If the of-ficer who responds identifies the situation asbeing non-violent, they will take the person tothe reception centre for evaluation. If the per-son is armed or threatening, the crisis negotia-tion teams respond.

The Los Angeles police have a two-compo-nent program. If officers in the field encountersomeone who appears to have a mental illnessand has been involved in a low-grade misde-meanor, they bring the person to a mental healthevaluation unit for assessment and referral. Themental health evaluation unit is staffed by po-lice officers that are trained in assessment andreferral. This unit also:

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• provides consultation to officers in the field• creates a database of resources and persons

with a mental illness who use police services• provides training to different departments• assists relatives

This unit does not address situations wherethe person is violent or threatening; for thosesituations, Los Angeles uses a specially-trainedoutreach team.

In Birmingham, a civilian team of officersresponds to repeated calls for service or to men-tal health calls where police service is unneces-sary. In general, this team is in charge at the siteand allows the police officers to return to theirother duties. They work closely with the person’sfamily and the mental heath and hospital ser-vices. The police remain on-site only if violenceis a concern, or as long as it takes to accompanythe individual to hospital. The civilian officerremains at hospital while the police officer re-turns to duty. Following intervention, they in-form the police officers of the disposition andregularly review referrals.

The Car 87 police/mental health team inVancouver takes action that depends on the re-sult of an in-depth assessment. The team maytake the individual to hospital, they may admiton an emergency basis to a care facility, or theymay provide medication and reassurance to thoseinvolved. Regardless, they will make a referralto the appropriate resource and the team willnotify the person who made the emergency re-ferral of the outcome.

In Madison, Wisconsin, a mental-health-based crisis intervention team is available byphone, on the scene, or to provide follow-up.Officers are provided with 5 possible disposi-tion options and guidelines for choosing each.For example, the police are required to consultwith mental health staff before detaining or trans-porting someone to hospital, and officers havethe authority to place violent people into thestate psychiatric facility. They also can overrulethe evaluating psychiatrist if the psychiatrist doesnot recommend temporary custody.

The After-Hours Team in Kamloops, BC,provides support to police in several ways. If theRCMP requires assistance, the team will pro-vide assessments and advice in jail; if the personis too intoxicated to be assessed, the team willreturn when they are sober. Team members willalso provide a bridge between the mental health

system and the police so that people do get con-nected to services by arranging to do follow-upvisits and by offering appointments to thosepeople who are detained and released withoutcharges.

The team will also meet the officers on thestreet and provide advice about known clients,and provide consultation for people who areexperiencing psychiatric crises but who are notclients. If the individual requires hospitalization,the mental health team will provide assistanceand advice to assist the officer to have them ad-mitted. RCMP also provides assistance when thecrisis team requires it.

It is clear from these descriptions that po-lice can potentially have a wide range of op-tions and discretionary powers when dealingwith a person experiencing a psychiatric crisis.The form of these responses varies consider-ably. Some employ mental health profession-als, others employ specially-trained police of-ficers, and others use teams that combine po-lice and mental health professionals. Some pro-grams have a two-stage process while othershave one stage. It appears that they all includea method of assessing the person’s functioning,and match that to a range of dispositions. Gen-erally, responses differ if there is a perceivedrisk of violence. In some programs, a morehighly trained ream intervenes in that event.In other programs, there is one team that hasavailable a continuum of escalating options.

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Appendix 4Web Sites Providing Useful Informationabout Policing and Mental Illness

www.mhnet.orgMental Health net

www.nami.orgNational Alliance of the Mentally Ill

www.nmha.orgNational Mental Health Association

www.prainc.com/gains or GAINSCTR.comGAINS Center for Peoplewith Co-occurring Disorders

www.nih.govNational Institutes of Health

www.samhsa.govSubstance Abuse and Mental HealthAdministration

www.ncjrs.orgNational Criminal Justice Reference Service

www.rcmp-grc.orgRCMP

www.policeforum.orgPolice Executive Research Forum

www.usdoj.govUS Department of Justice

www.ojp.usdoj.govOffice of Justice Programs,Department of US Justice

www.fbi.govFBI

Appendix 5People Interviewed or Who ProvidedInformation for This Project

Karen Abrahamson, Consultant

Gary Bell, RCMP Cadet Training Institute

Kim Bell, Peel Branch, CMHA Ontario Division

Marilyn Blackett, Kamloops Mental Health Centre

Keith Bromwell, RCMP, Dartmouth

Brian Case, National GAINS Center, PolicyResearch Associates

John Chisholm, Kamloops RCMP

Sam Cochran, Memphis Police Force

Peter Collins, Ontario Provincial Police

Dorothy Cotton, Forensic Services, ProvidenceContinuing Care Center, Kingston, Ontario

Lucy Costa, Queen Street Outreach Services

Richard Dolman, BC Schizophrenia Society

Simon Davis, Inter-ministerial Program,Vancouver, BC

Eric Fabris, Queen Street Outreach Services,Toronto

Marianne Farmer, Justice Institute of BC

Cynthia Gass, Knoxville Police Force

Bill Gaudette, Canadian Mental HealthAssociation, President

Gary Glacken, BC Schizophrenia Society

Gord Glasgow, RCMP Training Institute

Art Gondziola,Saskatchewan Schizophrenia Society

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Jamie Graham, Chief of Police,Vancouver Police Department

Dave Jones, Vancouver Police

Nancy Hall, former Mental Health Advocate,Province of BC

Margaret Hansen, Riverview Hospital

Tomi Hamner, New Westminster Police

Darryl Kean, Police Consultant, Surrey, BC

Laurie Koziak, Mental Patients Association

Ron Lajeunesse, Alberta Division,Canadian Mental Health Association

Scott Maywood, Toronto Police

Lori McPherson, CMHA Winnipeg

Joan Montgomery,Canadian Schizophrenia Society

Barry Niles, Mental Patients Association

Richard Offer, Police Complaints Authority, UK

Jim Ogloff, Monash University,Melbourne, Australia

Janet Peters, Mental Health Consultant,New Zealand

Nancy Panagabko, Crisis InterventionConsultant

Richard Parent, Delta Police

Irene Ralph, Grand Forks After Hours Service

Melissa Reuland, Police Executive Research Forum

Lorri Ross, Emergency Health Services,Vancouver

Heidi Schoenberger, Vancouver Police

Fred Smith, Dawson Creek Mental HealthCentre

Julian Somers, Mental Health Evaluation andConsultation Unit, UBC

Linda Teplin and Judith Wray,Northwestern University

Mike Webster, Centurion Consultants,Denman Island BC

Jennifer White, formerly of the Mental HealthEvaluation and Consultation Unit, UBC

30


Executive SummaryIntroductionIn October 2000, the BC Chief Coronerissued a report following an inquest. After aseries of aggravating incidents, a man who wasdistressed and suffering from a mental illnessbegan acting violently in the emergencydepartment of a BC hospital. The police werecalled, the situation escalated, and in theensuing confrontation the individual died.

The Coroner made a number ofrecommendations to various governmentMinistries relevant to the situation. One of theCoroner’s many recommendations is the focusof this report. It was:• That police be provided training with

respect to dealing with people with a mentalillness in a non-confrontational manner.

CMHA BC was an intervenor in thatCoroner’s Inquest, and in carrying out thisproject, seeks to help the various relevantparties move forward on the keyrecommendation above. The specificobjectives of this project are to:• find out what kind of training is offered to

police in different jurisdictions, todetermine the common program elements,and to attempt to identify the mosteffective components;

• review the literature to determine what servicedelivery models are being used by police invarious jurisdictions to intervene in crises;

• determine key aspects and key strategies forimplementation, i.e. those key factors thatcontribute to the establishment of effectiveintervention programs.

This report relied on published research andreports, as well as interviews with individualswho work for or with police departments,including mental health professionals. It alsoincluded information gained from Coroner’sreports and interviews with individuals whoparticipated in inquiries.

Outline of the ReportThe first part of this report looks at the nature ofthe problem, by first looking at why more peoplewith a mental illness are coming into contact withthe police, and identifying a number of factors

that have contributed to this trend. The reportthen looks at some of the factors that createbarriers to effective police response to persons withmental illness, and next, looks at two key issuesthat have resulted from this state of affairs:criminalization and injury or death of personswith mental illness (as well as serious personalconsequences for the police officers involved).

The second part of the study looks at solutions,describing different intervention “prototypes”designed to assist individuals who are inpsychiatric crisis who come into contact with thepolice, and identifying key attributes of eachmodel, and key attributes of successful programsin general.

Key FindingsBackgroundA number of factors that have lead peoplewith mental illness to come into increasedcontact with the police, including:• deinstitutionalization, especially problems

with crisis response and other communitysupport that would avert crises fromhappening in first place

• the move to “community policing” thatincreases day to day contact between policeand individuals in the community.

This combination of factors, and others, haveplaced police in the position of being afrequent “first responder” in situationsinvolving mental illness, usually without thenecessary training or backup to deal effectivelywith such situations.

Barriers to effective responsePolice face a number of barriers in theirattempt to successfully resolve situationsinvolving mental illness. These include:• lack of knowledge, including general

knowledge about mental illness, includingsigns and symptoms

• misconceptions about people with mentalillness (shared with the general public)

• lack of specialized training re mental illnessand non violent crisis response

• lack of situational knowledge orconsultation (i.e. background informationre whether a given situation involvesmental illness)

• lack of responsiveness of crisis and acute

31


care mental health system, resulting in:• officers spending long periods of time

in emergency departments• officers making an arrest instead of a

referral in hopes of initiatingtreatment (especially in situationswhere a minor crime has beencommitted)

• officers avoiding mental illness-relatedsituations in some cases, especially in“nuisance” situations or in cases wherethe individual is seen as quite difficultto deal with by either the mentalhealth or criminal justice systems)

The result of this state of affairs is that toomany people certain people ignored or remainuntreated, (especially in situations where dualdiagnosis is involved).

Another result is an unnecessarycriminalization, trauma, injury or death ofpeople with mental illness. It must not beforgotten that police officers, too, are left insituations that may be dangerous forthemselves, with little access to specializedconsultation or backup.

Specialized ResponsesThe next part of the report looks at specializedresponses that have arisen to improve thecurrent state of affairs. The research reviewedreform efforts from across North America,with particular attention to the CrisisIntervention Team (CIT) model, which aroseout of Memphis Tenessee, and has beenreplicated with various modifications in otherAmerican jurisdictions. In addition to theCIT model, the research identified three otherresponse prototypes. The table on the nextpage outlines each of these models, togetherwith a consideration of their respectivestrengths and weaknesses.

Key Attributes of Successful ProgramsWhen the programs are looked at as a

whole, a number of key features emerge as keyattributes that contribute to success. Theseinclude: leadership; extensive specializedtraining; access to information andconsultation; a staged response continuum;close collaboration with the mental healthsystem; and comprehensive coverage. Itappears that the Memphis Crisis Intervention

Team (CIT) model possesses more of thesecharacteristics than the others, but each modelhas its own set of strengths and weaknessesthat need to be considered. The followingsection outlines each of these attributes ingreater detail.

Leadership/Clear Mandate• need for high level leadership from both

police and mental health systems• leadership from advocacy community is

also key• police buy-in regarding need for change

often relies on internal champions as wellas municipal leadership (e.g. from Mayor)

• reform efforts often triggered by tragedy orby specific incident

Extensive Specialized Training of a CoreGroup of Carefully Selected Officers• non violent crisis intervention a key feature

(communication, negotiation, de-escalation, specific to mental illness)

• cross-training between police and mentalhealth system (Madison model)

• experiential training (consumers/familiescross train police; Queen St. Torontomodel)

• practical/hands on training (selecting andtraining specialized officers – Memphismodel – means that officers can “put skillsinto play” on regular basis)

• dispatcher training also a key feature ofCIT model

• training should be based on stagedintervention continuum (see below)

Information/Consultation• specialized information systems provide

opportunity to provide relevant on-siteinformation from dispatcher to officers onscene (e.g. if person has a mental healthhistory or history of violence, etc.)

• information systems can track trends overtime (e.g. where calls are coming from;what types of calls are most problematic,etc.) and can offer valuable system baselineinformation (Memphis found that over40% of police work involved mental healthsituations) or outcome information (reboth successes and ongoing troublespots)

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Specialized Responses: Summary Table of Responses

• single team• staffed by

mental healthprofessionalswho are “civilianofficers”

• takes referralsfrom patrolofficers in caseswhere resolvablewith non-violentcrisis interven-tion

• swat-like teamintervenes ifviolence

• single team• staffed by

police &mental healthprofessional

• team memberscan consultover phone,resolvesituation onsite, refer tocrisis residen-tial facility orhospital

• all officersreceive basictraining inregards tomental illness

• bring suspectedcases of mentalillness to“assessmentcentre”

• assessmentcentre staffed bymental healthprofessionalswho are policeemployees

• specialized teamintervenes ifviolence

• specialized police crisisintervention teams

• specially trained officerwithin each “catchmentarea” of city responds to all911 mental health callsfrom public or from patrolofficers within each city“catchment area”

• specially trained dispatch-ers provide backupinformation to officers ormake referral to mentalhealth system

• CIT officer resolves on sitewith crisis intervention,refers to mental healthsystem or brings to medi-cal centre

• medical centre has “noreject” policy

• has co-located mentalhealth / substance useservice

• single team haslimited capacityto respond tocalls

• considerabletraining / person-nel costs forpolice

• strength is on-site crisis resolu-tion

• single teamand limitedresponsecapacity

• a model thathas beenwidely repli-cated inCanada

• limited re-sponse sinceone assessmentcentre coversentire area

• relativelylimited on-siteresolutioncapacity

• strong geographic andafter-hours coverage

• only model to have sub-stantial positive researchbacking (satisfaction ofconsumers/families andpolice; time efficient forpolice; less involuntarycommitment; less traumafor police

• relies on close, formalizedcollaboration with mentalhealth system

PrototypesMobile team –Police-based

Mobile team –MH Based

AssessmentCentre

Crisis InterventionTeam (CIT) model

Example

Definition/KeyAttributes

Considerations

Birmingham, AL Car 87Vancouver, BC

Knoxville, TNLos Angeles, CA

Memphis, TN

• mental health professionals and police needto establish, within legal and ethicalframeworks, effective ways of sharinginformation

Staged Response Continuum• developing ongoing positive relationships

with mental health community and withmental health consumers is first stage

(proactive/preventive) part of continuum• non-violent crisis intervention is basis of

intervention• back-up for more potentially violent cases

is necessary (e.g. from specially trained swatteam or negotiation team that is trained inappropriate use of “non-lethal” weapons,e.g. stun guns or TASER)

• close collabaration with mental healthsystem a must (referral to regular crisis or

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Conclusions/RecommendationsBC should develop a comprehensive strategyfor addressing the needs of people with amental illness who come in contact with thepolice. This strategy needs to include specialpolice units that incorporate the criticalcomponents of effective programs. At aminimum they should:• collaborate with the consumers, families,

and the mental health, addictions, andsocial service systems in the design andimplementation phase

• screen and provide ongoing training andsupport to specially trained officers,

• ensure that dispatchers and regular officersare trained to support these units

• within appropriate legal and ethical frame-works, collect information and provideofficers with access to key records aboutpolice contacts with people who havemental illness

• develop protocols for police and mentalhealth system collaboration, and mecha-nisms for resolving disputes as they arise

• evaluate their impact on the people they areserving

This strategy needs to be based on a collabora-tive approach between police, mental healthservices, and the mental health advocacycommunity. It must also be flexible enough tomeet the unique needs of remote and ruralcommunities, as well as urban centres, recog-nizing the diverse ethnocultural andgeographic needs of each.

acute care services where possible)• special attention to concurrent substance

use seen as a key issue in many programs

Close collaboration with mental health system• response protocols specifying mutual

responsibility, and enabling efficientreferrals and information sharing

• access to dispute resolution• high level mandate within each department• “no-reject” service by mental health system

seen as key; i.e., need to establish agreementthat individuals referred by police to acuteor community mental health services willreceive appropriate service

• special attention to concurrent substanceuse seen as a key issue in many programs

Comprehensive Coverage• model should ensure after-hours response• chosen model should ensure geographic

coverage and ability to respond to morethan one call at a time

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